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Original Article
Epidemiology Post-traumatic stress disorder, anxiety, and depression in North African intensive care unit survivors: a prospective observational study
Acute and Critical Care 2025;40(3):402-412.
DOI: https://doi.org/10.4266/acc.000150
Published online: August 29, 2025

1Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia

2Medical Intensive Care Unit, Research Laboratory LR12SP09 "Heart Failure", Farhat Hached University Hospital, Sousse, Tunisia

Corresponding author: Mohamed Boussarsar Medical Intensive Care Unit, Research Laboratory LR12SP09 "Heart Failure", Farhat Hached University Hospital, 1 St Ibn AL Jazzar, Sousse 4000, Tunisia Tel: +216-5-298-6000, Email: hamadi.boussarsar@gmail.com
• Received: December 25, 2024   • Revised: July 9, 2025   • Accepted: July 11, 2025

© 2025 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Background
    Survivors of critical illness often face significant physical and psychological challenges, including post-traumatic stress disorder (PTSD), anxiety, and depression, which can severely impact their quality of life. This study aimed to evaluate the prevalence and associated factors of PTSD, anxiety, and depression among intensive care unit (ICU) survivors 3 months after discharge, and investigate the prevalence and determinants of post-intensive care syndrome–related neuropsychiatric disorders (PICS-ND).
  • Methods
    This is a prospective observational analytical study carried out in a medical ICU. Three months after discharge from the ICU, survivors were contacted by telephone to complete the Impact Event Scale-Revised and Hospital Anxiety and Depression Scale questionnaires. Univariate and multivariate analyses were performed to identify variables that were independently and significantly associated with outcomes.
  • Results
    A total of 114 survivors was enrolled. At 3 months, PTSD, anxiety, and depression were prevalent in 21.9%, 21.0%, and 9.6% of patients, respectively. Associated factors were younger age, female, physical restraint, and critical illness polyneuropathy and myopathy (CIPNM) for PTSD; unmarried, low Charlson index, and physical restraint for anxiety; and younger age and CIPNM for depression. PICS-ND, a composite measure of neuropsychiatric morbidity, was present in 28.9% of patients, with younger age, female, and physical restraint identified as associated factors.
  • Conclusions
    PTSD, anxiety, depression, and PICS-ND were common among ICU survivors at 3 months. Various factors, including younger age, female, unmarried, lower Charlson index, physical restraint, and CIPNM, were associated with these psychological outcomes.
  • Key Words: anxiety; follow-up studies; critical illness; post-traumatic stress disorder
Although advances in critical care have improved outcomes for patients admitted to intensive care units (ICUs), where complex medical interventions are used to manage life-threatening conditions [1,2], the convalescence process after ICU discharge is often a physical and psychological challenge [2]. Severe stress, respiratory insufficiency, lack of communication, and sleep disturbance can predispose patients to functional and psychiatric disorders [3].
The appearance of a new disability or decline in physical, intellectual, or psychological conditions after an ICU stay is recognized as post-intensive care syndrome (PICS) [2,4,5]. The psychiatric dimensions of PICS are reported in approximately one-third of ICU survivors [6,7]. The most common psychiatric conditions following critical illness are post-traumatic stress disorder (PTSD), anxiety, and depression [2]. These mental health conditions are more than just sequelae; they can significantly hinder recovery and decrease overall quality of life [8]. Detecting predictors of post-ICU mental health problems could help identify high-risk patients and plan appropriate care strategies [3,6]. Studies evaluating mental health outcomes of ICU survivors in North Africa are rare. Existing systematic reviews primarily focus on high-income countries, with limited data from low- and middle-income countries [3,9,10].
The aim of this study was to determine the prevalence of PTSD, anxiety, and depression in survivors of critical illness in a North African medical ICU at 3 months post-discharge and identify factors associated with these psychological outcomes. We hypothesized that PTSD, anxiety, and depression are prevalent in ICU survivors at 3 months, and that specific demographic and clinical factors are independently associated with these outcomes. We also explored the prevalence and associated factors of post-intensive care syndrome–related neuropsychiatric disorders (PICS-ND), a composite measure of neuropsychiatric morbidity. 
The study was approved by the Ethics and Research Committee of Farhat Hached University Hospital, Sousse, Tunisia (IORG 0007439 ERC 02092023 Office for Human Research Protection – U.S. Department of Health and Human Services). The voluntary and anonymous nature of the study was explained to the patients. Informed consent was obtained from all participating patients.
Study Design
A prospective observational analytical study was carried out between January 2017 and January 2018 in a nine-bed medical ICU. This unit was managed by dedicated intensivists, with a team including a department chief, one associate professor, four assistant professors, six ICU-dedicated residents, and four interns. The unit is supported by 16 nurses, maintaining a 1:2 nurse-to-patient ratio, and two physiotherapists. These physiotherapists provide daily early mobilization sessions, ranging from passive to active exercises, aimed at minimizing muscle weakness and functional decline during the ICU stay. Family visits, which can play a crucial role in patient well-being and recovery, are permitted daily for 1 hours (2 PM to 3 PM). Patient demographics and clinical data were collected upon ICU discharge using a standardized form. Three months following their discharge, patients were contacted by telephone to complete Impact Event Scale–Revised (IES-R) and Hospital Anxiety and Depression Scale (HADS) questionnaires. Patients with abnormal scores (IES-R ≥33 or HADS >11) were informed of their results and were referred for a psychiatric consultation.
Sample Size
Given the observational nature of the study and to provide representative and credible data, the required sample size was calculated using the formula [11].
N=(Z²×P×[1−P])/i²
where N is the required sample size; Z is the Z score corresponding to the desired confidence level (1.96 for 95% confidence); P is the reported prevalence of PTSD (0.17) [12], anxiety (0.16) [13], and depression (0.098) [14]; and i is an arbitrary degree of precision (7%). Using this formula, the estimated sample sizes for PTSD, anxiety, and depression were 111, 106, and 70 patients, respectively.
Population
All consecutive patients admitted to the medical ICU during the study period were screened. ICU survivors who consented to participate in the study were subsequently considered for inclusion. Exclusion criteria were dementia, pre-existing psychotic illnesses, prior mood disorders, and hospitalization for less than 24 hours. We also excluded participants who could not be contacted after three telephone calls within 1 week or those who died before the 3-month follow-up.
Study Outcomes
This study primarily investigated three psychological outcomes: PTSD, anxiety, and depression. Additionally, PICS-ND was explored as a secondary outcome of interest to assess its overall prevalence and associated factors.
Collected Data
Patient characteristics during their ICU stay were collected from medical records by a trained resident physician with 3 years of experience (MZ). A standardized protocol outlining clear definitions and a uniform data collection form ensured consistency in the data abstracted from charts. The following characteristics were collected: sociodemographic information (age, sex, socioeconomic status, education level, marital status, tobacco and alcohol consumption), Charlson index, Simplified Acute Physiology Score (SAPS) II score, diagnosis, and therapeutic interventions in the ICU (invasive/noninvasive ventilatory support, catheterization, hemodynamic support by inotropes/vasopressors, administration of sedatives, and physical restraint). Outcomes and adverse events, such as critical illness polyneuropathy and myopathy (CIPNM), pressure ulcers, ventilator-associated pneumonia, duration of invasive mechanical ventilation (IMV), and length of ICU stay, were recorded. Three months after ICU discharge, patients were contacted by telephone by a trained critical care resident (MZ) to assess their survival status and complete the IES-R and HADS questionnaires.
Applied Definitions
The Charlson comorbidity index (CCI) [15], developed by Charlson et al. in 1987, is a tool used to assess comorbidities and chronic disease burden. This weighted index considers both the number and seriousness of comorbid diseases to estimate mortality risk. The SAPS II [16] is a scoring system used in ICUs to assess the severity of illness and predict the mortality risk of critically ill patients. It measures physiological variables such as vital signs, age, and underlying health conditions to provide a numerical score that indicates the patient’s overall condition and prognosis. A higher SAPS II score corresponds to a higher predicted mortality risk. The CIPNM [17] was assessed with the Medical Research Council (MRC) sum score as determined by a physiotherapist to evaluate muscle force in patients suspected of having this condition. An MRC total score less than 48 was used as the threshold for diagnosing CIPNM. PTSD symptoms were evaluated using the 22-item IES-R. All items are scaled from 0 to 4, with overall scores ranging from 0 to 88. Scores greater than 20 represent clinically significant reactions, and scores greater than 33 represent severe symptoms that are highly predictive of PTSD [18].
Physical restraint was defined as application of purpose-designed pressure to a patient’s wrists to prevent them from removing essential medical devices such as tubes or catheters [19]. This intervention was exclusively performed under medical prescription, primarily to ensure patient safety. In the present study, physical restraint was documented as a binary variable (presence or absence). The HADS tool was used to assess anxiety and depression. This scale was developed to detect psychiatric symptoms in patients with general medical problems [6,13,20]. The HADS anxiety and depression subscales each comprise seven items, and each item is scored on a 4-point scale; possible scores for both subscales range from 0 to 21. Point prevalence, based on standard cutoff thresholds of 8 and 11, is commonly used in critical care research and recommended by the original HADS validation study [9]. A cutoff ≥8 is often used to suggest the presence of clinically significant anxiety or depression. A cutoff ≥ 11 is sometimes used to increase the test specificity and reduce the number of false positives. For the present study, a cutoff ≥ 11 was chosen [21].
PICS-ND is defined as new or worsening impairments in physical, cognitive, or mental health that persist after critical illness [2]. For this study, PICS-ND was defined by the co-occurrence of clinically significant symptoms of PTSD (IES-R ≥33), anxiety (HADS-A ≥11), and/or depression (HADS-D ≥11), as assessed by the respective scales. Patients meeting the criteria for at least one of these conditions were categorized as having PICS-ND.
In the present study, Arabic versions of IES-R and HADS were used. The Arabic version of the IES-R was developed using World Health Organization principles [22]. The reliability of this version and its subscales (intrusion, avoidance, and hyperarousal) demonstrated good consistency, with corresponding α values of 0.93 for the overall scale and of 0.77, 0.75, and 0.86 for intrusion, avoidance, and hyperarousal subscales, respectively [22,23]. The reliability of the Arabic version of the HADS scale was also validated for identifying anxiety and depressive problems. The overall Cronbach’s alpha coefficients measuring internal consistency were 0.7836 and 0.8760 for anxiety and depression, respectively [24].
Statistical Analysis
Statistical analyses were performed using IBM SPSS version 24.0 (IBM Corp.). Distributions of variables were analyzed using the Kolmogorov-Smirnov test. Continuous variables are presented as the mean±standard deviation, median, and interquartile range. Comparisons between two groups were conducted using independent-sample t-tests for variables demonstrating normal distribution, while the Mann-Whitney test was employed for quantitative variables displaying non-normal distribution. Pearson’s chi-square test and Fisher’s test were used for categorical variables. Correlations between continuous variables were calculated using Spearman’s correlation coefficients. A Venn diagram was used to evaluate overlapping symptoms.
To identify variables that were independently and significantly associated with our primary outcomes, logistic regression analysis was performed. Separate multivariate analyses were conducted for each distinct psychological outcome: PTSD (IES-R ≥33), anxiety (HADS-A ≥11), and depression (HADS-D ≥11). This approach was chosen because PTSD, anxiety, and depression are distinct clinical entities, and analyzing them separately helped prevent overfitting while improving the interpretability of predictors for each specific condition. Univariate and multivariate analyses were conducted to identify factors independently and significantly associated with PICS-ND.
To mitigate the risk of type I error and to guide variable selection for each respective outcome (PTSD, anxiety, depression, and PICS-ND), only variables with a p-value less than 0.05 in the univariate analysis were included in the multivariable binary logistic regression models. A backward-elimination stepwise approach was performed. Results of the regression models were expressed as odds ratio with a 95% CI.
Between January 2017 and January 2018, 261 patients were admitted to the study hospital’s ICU. Of these, 191 patients (73.18%) were discharged alive. Among these, 16 (8.3%) did not meet the inclusion criteria. Between enrollment and the 3-month follow-up, 21 patients (11%) died and 40 (20.9%) were never successfully contacted. This left 114 patients (59%) eligible for the 3-month assessments related to ICU-induced PTSD, anxiety, and depression. A study flowchart is provided in Figure 1. A comparative analysis of patients lost to follow-up and study completers revealed no statistically significant differences in baseline characteristics (Supplementary Table 1)
Patient Characteristics
Patient characteristics are summarized in Table 1. Most patients (57.8%) were males with a median age of 60 years (interquartile range [IQR], 44–70). Fifty-nine patients (51.7%) were smokers and 13 (11.4%) were alcohol consumers. The median CCI and SAPS II scores were 1 (IQR, 1–2) and 25 (IQR, 17–31), respectively. Respiratory distress was the most frequent reason for admission, in 79 patients (69.3%). Forty-seven patients (41%) received both IMV and sedation. Thirty patients (26%) required vasopressors. Central-line catheterization was performed in 33 patients (29.2%). Physical restraint was needed for 39 patients (34.2%). The median length of stay was 6 days (IQR, 4–10). Fourteen patients (12.3%) developed ventilator-acquired pneumonia.
Mental Health Outcomes
Using an IES-R cutoff ≥33, PTSD was found in 25 patients (21.9%). The median IES-R was 19 (IQR, 14–28). Twenty-four ICU survivors (21.0%) showed symptoms of anxiety (HADS-A >11). The median HADS-A score was 4 (3–10). Eleven ICU survivors (9.6%) showed symptoms of depression (HADS-D >11). The median HADS-D score was 5 (IQR, 4–6). PICS-ND was present in 33 patients (28.9%).
Correlation of Mental Health Outcomes in ICU Survivors at 3 Months Post-ICU Discharge
Spearman’s correlation analysis revealed that PTSD severity was significantly and positively correlated with the severity of depression and anxiety symptoms (r=0.473, P=0.000; r=0.662, P=0.000). A positive correlation was observed between severity of anxiety and depression symptoms (r=0.196, P=0.037).
Co-occurrence of Mental Health-Related Symptoms
A Venn diagram for PTSD, anxiety, and depression is shown in Figure 2. Five of 25 patients (20%) with PTSD had both anxiety and depression, and five of 24 patients with anxiety (20.8%) had depression.
Factors Associated with Mental Health Outcomes
As illustrated in Table 1, which presents the findings of the univariate analysis, several factors demonstrated associations with PTSD among ICU survivors at 3 months after discharge. These included age; sex; alcohol consumption; Charlson index; SAPS II score; IMV; sedative use; central-line catheterization; physical restraint; and durations of IMV, CIPNM, and ventilator-acquired pneumonia (VAP). Similarly, a univariate analysis revealed that various factors were linked to anxiety. These included younger age, female, married, Charlson index, IMV, sedative use, central-line catheterization, physical restraint, CIPNM, VAP, and duration of IMV.
Depression was associated in the univariate analysis with younger age, SAPS II score, CIPNM, physical restraint, and duration of IMV. For PICS-ND, the univariate analysis identified associations with younger age, female, married, Charlson index, SAPS II score, IMV, sedative use, central-line catheterization, physical restraint, CIPNM, VAP, and duration of IMV. All variables with a P-value less than 0.05 in the univariate analysis were subsequently included in the initial multivariate models and are detailed with their crude odds ratios in Supplementary Table 2. As displayed in Table 2, in the final multivariate regression models, younger age, female, physical restraint, and CIPNM were independently associated with PTSD. Not married, a lower Charlson index, and physical restraint were associated with anxiety. Younger age and CIPNM were independently associated with depression. Age, female, and physical restraint were associated with PICS-ND.
The present study investigated the long-term mental health impact of ICU stay on survivors at 3 months after discharge, revealing a significant prevalence of PTSD, anxiety, and depression. These conditions were particularly common among younger adults, females, individuals who experienced physical restraint during their ICU stay, and those with CIPNM. PICS-ND, which is a composite measure of neuropsychiatric morbidity, was also prevalent, with age, sex, and physical restraint identified as associated factors. A significant and positive correlation was noted between anxiety and PTSD, between PTSD and depression, and between anxiety and depression among ICU survivors at 3 months after ICU discharge. A high degree of symptom co-occurrence between these three conditions was observed.
Mental Health Outcomes
Nearly one-fifth of ICU survivors had symptoms of PTSD. This finding aligns with 3-month follow-up studies [20,10] in which the median prevalence ranged from 9% to 30% and is consistent with a systematic review by Righy et al. [3], who reported a pooled prevalence of 25.69%. Anxiety symptoms were detected in 21% of ICU survivors at 3 months post-discharge, a result comparable to those of similar studies [25-27]. This is also comparable to a meta-analysis by Nikayi et al. [9] that found a pooled prevalence of 17% at 2 to 3 months. The frequency of depression in ICU survivors at 3 months after discharge was 9.6%. This finding is lower than the 17% pooled prevalence reported in a systematic review by Rabiee et al. [10] at 2 to 3 months after critical illness. This difference may be explained by the inclusion of patients with prior psychiatric problems before hospital admission in numerous studies within the meta-analysis, potentially leading to an overestimation of depression prevalence. While we investigated PTSD, anxiety, and depression as distinct psychological outcomes, these conditions are integrally linked and overlap significantly with the broader framework of PICS [28].
Factors Associated with Mental Health Outcomes

Post-traumatic stress disorder

The current study found that age was independently associated with PTSD at 3 months after ICU discharge. This result supports prior research showing that younger survivors of critical illness are more susceptible to PTSD compared with older patients [29,30]. The possible reasons for this association are that older patients may not perceive their ICU stay as a traumatic experience because they already have other health issues, previous hospitalization experience, and greater adaptability to prolonged impairment compared with younger patients [30]. Our findings align with those of previous research that found higher rates of PTSD symptoms among women recovering from critical illness. In their systematic review, Davydow et al. [31] found that PTSD was associated with female sex in two of seven studies, while no study has reported an association with male sex. Physical restraints are commonly used in ICUs to prevent patients from removing devices or falling. Although the main purpose is patient safety, their use can inadvertently lead to physical or psychological harm [19]. In our study, physical restraint was associated with PTSD in ICU survivors, which is consistent with previous findings that linked memories of physical restraint to PTSD symptoms [32]. However, the evidence regarding how physical restraints contribute to PTSD is limited, with a recent systematic review identifying only a few studies of this relationship [19].
CIPNM was also independently associated with PTSD in ICU survivors at 3 months after ICU discharge. Inflammation, malnutrition, and limited physical activity during critical illness can contribute to the development of ICU-acquired weakness, which includes conditions such as CIPNM. The physical impairments induced by CIPNM, including exercise limitations, fatigue, impairment of activities of daily living, and shortness of breath, can significantly affect the quality of life and interfere with the well-being and mental health of ICU survivors [33].

Anxiety

Marital status significantly influenced anxiety, with single ICU survivors in this study more likely to experience anxiety than married patients, possibly due to the critical social and emotional support often provided by a spouse during recovery. Higher CCI, indicating more severe comorbidities, was associated in this study with a lower risk of anxiety after ICU discharge. This finding could be explained by the improved emotional coping strategies that often accompany management of several chronic illnesses and frequent hospitalizations.
Similar to PTSD, physical restraint was associated with anxiety in the present study.

Depression

Younger age and CIPNM were predictors of depression in ICU survivors. Jackson et al. [34], who reported similar findings, proposed that physical and occupational rehabilitation could be a promising strategy for somatic depression in ICU survivors. The findings of the present study are also consistent with a systematic review and meta-analysis conducted by Rabiee et al. [10].

Co-occurrence of Mental Health-Related Symptoms

We found that all three psychological outcomes were strongly correlated, as in several previous studies and meta-analyses [10,13,25,35]. The significant co-occurrence of mental health-related symptoms in the aftermath of critical illness profoundly affected recovery trajectories and overall quality of life, underscoring the interconnected nature of these challenges along the PICS spectrum [28]. From a clinical perspective, these findings underscore the importance of a PICS-informed approach to post-ICU care. Given the observed prevalence rates and the known comorbidities among these psychological conditions, routine screening for PTSD, anxiety, and depression is essential in follow-up care [10]. Effective management of these intertwined psychological impairments is crucial for optimizing long-term recovery and addressing the comprehensive needs of ICU survivors. Early recognition of these potentially treatable conditions allows personalized management plans and preventative measures, ultimately improving patient outcomes and furthering translational research [36,37].
This study has several limitations. First, it was a single-center study. Second, self-reporting scales were used to assess psychological outcomes; clinical psychiatric interviews could provide a more comprehensive evaluation. Third, assessing PTSD, anxiety, and depression at 3 months after ICU discharge may not capture the dynamic nature of these conditions. Symptoms can change over time, and some ICU survivors may develop psychological issues beyond the 3-month mark. Fourth, the absence of a control group (non-ICU patients) prevented us from concluding causal relationships between ICU admission and the observed mental health outcomes; our findings only deal with associations and predictors within the ICU survivors. Fifth, a significant portion (29.3%) of eligible patients could not be contacted for the 3-month follow-up assessment. This loss to follow-up could introduce bias if those who were lost had different psychological outcomes than those who were successfully contacted. Sixth, a lack of pre-ICU mental health data was a limitation. While severe pre-existing psychiatric conditions (e.g., dementia, psychotic illnesses, or prior mood disorders) were excluded to mitigate confounding, future studies would benefit from comprehensive baseline assessments. Last, delirium was not assessed systematically using a standardized tool during the study period, which is a recognized limitation. However, our unit has since begun using a validated standardized tool, the Confusion Assessment Method for the ICU, for delirium diagnosis.
In conclusion, we found that PTSD, anxiety, depression, and PICS-ND were prevalent among ICU survivors 3 months after discharge. These mental health problems were linked to younger age, female, single marital status, lower comorbidity burden, and specific ICU experiences including physical restraint and CIPNM. Following the COVID-19 pandemic, during which patient characteristics, pathologies, and management differed significantly from pre-pandemic ICU observations, patient profiles, pathologies, and management strategies common before the pandemic are returning. We believe that this study provides valuable insights into the mental health challenges faced by ICU survivors in North Africa. Future research is warranted to comprehensively investigate the psychological outcomes of ICU survivors in low- and middle-income countries, given the unique challenges faced by these populations. Such research will inform the development and implementation of targeted interventions aimed at reducing the psychological burden of critical illness and intensive care.
▪ At 3 months post-discharge, intensive care unit survivors frequently experience post-traumatic stress disorder, anxiety, and depression.
▪ Risk factors include younger age, female, physical restraint, and critical illness polyneuropathy.
▪ The frequent overlap of these conditions highlights the importance of comprehensive mental health screening and individualized care planning.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: IBS, MZ, MB. Methodology: IBS, MZ, MB. Formal analysis: IBS, MZ, MB. Data curation: IBS, MZ, SF. Visualization: IBS, MZ, MB. Project administration: IBS, MB. Writing – review & editing: IBS, MZ, SF, MB. All authors read and agreed to the published version of the manuscript.

Supplementary materials can be found via https://doi.org/10.4266/acc.000150.
Supplementary Table 1.
Comparative analysis of baseline demographic and clinical characteristics between patients lost to follow-up and study completers
acc-000150-Supplementary-Table-1.pdf
Supplementary Table 2.
Crude ORs and 95% CIs for factors included in the initial multivariate binary logistic regression models for mental health outcomes
acc-000150-Supplementary-Table-2.pdf
Figure 1.
Study flowchart. ICU: intensive care unit.
acc-000150f1.jpg
Figure 2.
Venn diagram illustrating. Post-traumatic stress disorder (PTSD), anxiety, and depression in intensive care unit survivors 3 months after discharge.
acc-000150f2.jpg
Table 1.
Baseline characteristics and univariate analysis of factors associated with mental health outcomes in ICU survivors at 3 months post-discharge
All patients (n=114) PTSD
 Anxiety
 Depression
 PICS-ND
Yes (n=25) No (n=89) P-value Yes (n=24) No (n=90) P-value Yes (n=11) No (n=103) P-value Yes (n=33) No (n=81) P-value
Socio-demographic characteristics and underlying diseases
 Age (yr) 60 (44–70) 43 (22–58) 63 (53–71) 0.000 43 (21–59) 62 (52–71) 0.001 40 (23–58) 62 (47–71) 0.009 41 (23.5–58) 60.5 (44.25–70) 0.000
 Female 48 (42.2) 15 (60.0) 33 (33.6) 0.023 15 (62.5) 33 (36.7) 0.023 8 (72.7) 40 (38.8) 0.065 22 (66.7) 26 (32.1) 0.001
 Low socio-economic level 53 (46.5) 12 (48.0) 41 (46.0) 0.600 15 (62.5) 38 (42.2) 0.077 4 (36.4) 49 (42.2) 0.479 19 (57.6) 34 (42.0) 0.131
 Primary school level 86 (75.4) 15 (60.0) 71 (79.7) 0.090 17 (70.8) 69 (76.7) 0.555 6 (54.5) 80 (77.7) 0.135 22 (66.7) 64 (79.0) 0.165
 No occupation 42 (36.8) 9 (36.0) 33 (37.1) 0.900 10 (41.7) 32 (35.6) 0.581 4 (36.4) 38 (36.9) 1.000 13 (39.4) 29 (35.8) 0.718
 Married 92 (80.7) 17 (68.0) 75 (84.3) 0.125 15 (62.5) 77 (85.6) 0.024 7 (63.6) 85 (82.5) 0.220 22 (66.7) 70 (86.4) 0.015
 Smoking 56 (49.12) 11 (44.0) 45 (50.6) 0.717 8 (33.3) 48 (53.3) 0.082 4 (36.4) 52 (50.5) 0.373 11 (33.3) 45 (55.6) 0.031
 Alcohol consumption 13 (11.4) 6 (24.0) 7 (7.8) 0.029 4 (16.7) 9 (10.0) 0.468 2 (18.2) 11 (10.7) 0.612 6 (18.2) 7 (8.6) 0.259
 CCI 1 (1–2) 1 (0–1) 1 (1–2) 0.043 1 (0–3) 1 (1–2) 0.004 1 (0–1) 1 (1–2) 0.165 1 (0–1) 1 (1–2) 0.002
 SAPS II 25 (17–31) 18.5 (14–27) 27 (18–32) 0.043 21 (14–26) 27 (18–32) 0.125 15 (13–24) 26 (18–32) 0.031 19 (13–26.5) 25.5 (16.75–31.25) 0.005
Reasons for ICU admission NA NA NA NA
 Respiratory distress 79 (69.3) 17 (68) 62 (69.7) 16 (66.7) 63 (70.0) 6 (54.5) 73 (70.9) 21 (63.6) 58 (71.6)
 Shock 9 (7.9) 2 (8) 7 (7.9) 2 (8.3) 7 (7.8) 1 (9.1) 8 (7.8) 3 (9.1) 6 (7.4)
 Neurological disorder 7 (6.1) 2 (8) 5 (5.6) 2 (8.3) 5 (5.6) 0 7 (6.8) 2 (6.1) 5 (6.2)
 Metabolic disorders 7 (6.1) 2 (8) 5 (5.6) 2 (8.3) 5 (5.6) 0 7 (6.8) 3 (9.1) 4 (4.9)
 Sepsis 5 (4.4) 0 5 (5.6) 0 5 (5.6) 0 5 (4.9) 0 5 (6.2)
 Toxic exposures/poisoning 5 (4.4) 2 (8) 3 (3.4) 2 (8.3) 3 (3.3) 4 (36.4) 1 (1.0) 4 (12.1) 1 (1.2)
 Miscellaneous conditions 2 (1.8) 0 2 (2.2) 0 2 (2.2) 0 2 (1.9) 0 2 (2.5)
Intensive care unit course
 NIV 71 (62.2) 13 (52.0) 58 (65.2) 0.356 14 (58.3) 57 (63.3) 0.653 4 (36.4) 67 (65.0) 0.124 16 (48.5) 55 (67.9) 0.052
 IMV 47 (41.2) 18 (72.0) 29 (32.6) 0.000 18 (75.0) 29 (32.2) 0.000 8 (72.7) 39 (37.9) 0.056 23 (69.7) 24 (29.6) 0.000
 Sedative use 47 (41.2) 19 (72.0) 28 (31.5) 0.000 18 (75.0) 29 (32.2) 0.000 8 (72.7) 39 (37.9) 0.056 23 (69.7) 24 (29.6) 0.000
 Catheterization 33 (29.0) 14 (56.0) 19 (21.3) 0.002 13 (54.2) 20 (22.5) 0.002 5 (45.5) 28 (27.5) 0.369 16 (48.5) 17 (21.0) 0.004
 Physical restraint 39 (34.2) 18 (72.0) 21 (23.6) 0.000 17 (70.8) 22 (24.4) 0.000 7 (63.6) 32 (31.1) 0.044 22 (66.7) 17 (21.0) 0.000
Complication
 CIPNM 9 (7.9) 7 (28.0) 2 (2.2) 0.000 5 (20.8) 4 (4.4) 0.019 3 (27.3) 6 (5.8) 0.024 7 (21.2) 2 (2.5) 0.001
 VAP 14 (12.3) 7 (28.0) 7 (7.8) 0.013 6 (25.0) 8 (8.9) 0.074 3 (27.3) 11 (10.7) 0.134 8 (24.2) 6 (7.4) 0.030
 Pressure ulcers 7 (6.1) 3 (12.0) 4 (4.5) 0.160 2 (8.3) 5 (5.6) 0.637 2 (18.2) 5 (4.9) NA 3 (4.9) 4 (4.9) 0.418
Outcome (day)
 Length of IMV 0 (0–4) 4 (1–9) 0 (0–2) 0.000 4 (1–8) 0 (0–3) 0.000 2 (0–6) 0 (0–3) 0.043 3 (0–6) 0 (0–4) 0.000
 Length of stay 6 (4–10) 7 (4–15) 6 (4–10) 0.099 6 (4–14) 6 (4–10) 0.270 6 (3–10) 6 (4–10) 0.650 6 (3.5–14) 6 (4–10) 0.551

Values are presented as median (interquartile range) or number (%). Probability (p): comparison between the two groups (Wilcoxon-Mann-Whitney test for continuous data and chi-square test for categorical data).

ICU: intensive care unit; PTSD: post-traumatic stress disorder; PICS-ND: post-intensive care syndrome–related neuropsychiatric disorders; CCI: Charlson Comorbidity Index; SAPS: Simplified Acute Physiological Score; NA: not applicable; NIV: non-invasive ventilation; IMV: invasive mechanical ventilation; CIPNM: critical illness polyneuropathy and myopathy; VAP: ventilatory-acquired pneumonia.

Table 2.
Binary logistic regression analysis for factors independently associated with mental health outcomes: crude and adjusted odds ratios from prefinal and final models
Variable Prefinal model
 Final model
Crude OR (95% CI) Adjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value
PTSD Age 0.947 (0.921–0.973) 2.755 (0.489–15.53) 0.002 0.95 (0.92–0.98) 0.001
Female sex 3.167 (1.257–7.98) 4.751 (1.214–18.597) 0.025 3.88 (1.08–13.96) 0.038
Physical restraint 8.327 (3.061–22.652) 5.778 (1.512–22.08) 0.010 6.27 (1.66–23.67) 0.007
CIPNM 16.917 (3.244–88.207 9.702 (1.273–73.945) 0.028 11.15 (1.55–80.08) 0.017
Alcohol consumption 3.699 (1.115–12.272) 2,755 (0.489–15.530) 0.251 - -
Anxiety Married 0.281 (0.102–0.776) 0.275 (0.069–1.091) 0.066 0.20 (0.05–0.74) 0.016
CCI 0.434 (0.232–0.813) 0.474 (0.233–0.963) 0.039 0.44 (0.22–0.89) 0.022
Physical restraint 7.506 (2.753–20.464) 11.925 (3.48–40.861) 0.000 10.70 (3.26–35.17) 0.000
Female sex 2.879 (1.135–7.303) 2.694 (0.827–8.772) 0.100 - -
Depression Age 0.955 (0.922–0.988) 0.955 (0.903–1.037) 0.032 0.95 (0.91–0.985) 0.006
CIPNM 6.062 (1.271–28.914) 9.371 (1.583–55.467) 0.014 8.46 (1.53–46.70) 0.014
SAPS II 0.941 (0.882–0.99) 0.967 (0.903–1.037) 0.346 - -
PICS-ND Age 0.914 (0.308–0.965) 0.937 (0.906–0.969) 0.000 0.938 (0.907–0.970) 0.000
Female sex 4.231 (1.788–10.009) 8.087 (2.133–30.666) 0.001 7.980 (2.183–29.178) 0.002
Physical restraint 7.529 (3.062–18.518) 11.680 (2.816–48.449) 0.000 17.637 (4.585–67.85) 0.000
CIPNM 10.653 (2.207–54.427) 5.362 (0.726–39.583) 0.100 - -

OR: odds ratio; PTSD: post-traumatic stress disorder; CIPNM: critical illness polyneuropathy and myopathy; CCI: Charlson Comorbidity Index; SAPS: Simplified Acute Physiological Score; PICS-ND: post-intensive care syndrome–related neuropsychiatric disorders.

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      Post-traumatic stress disorder, anxiety, and depression in North African intensive care unit survivors: a prospective observational study
      Acute Crit Care. 2025;40(3):402-412.   Published online August 29, 2025
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    Post-traumatic stress disorder, anxiety, and depression in North African intensive care unit survivors: a prospective observational study
    Image Image
    Figure 1. Study flowchart. ICU: intensive care unit.
    Figure 2. Venn diagram illustrating. Post-traumatic stress disorder (PTSD), anxiety, and depression in intensive care unit survivors 3 months after discharge.

    Figure 1.

    Figure 2.

    Post-traumatic stress disorder, anxiety, and depression in North African intensive care unit survivors: a prospective observational study
    All patients (n=114) PTSD
    		 Anxiety
    		 Depression
    		 PICS-ND
    Yes (n=25) No (n=89) P-value Yes (n=24) No (n=90) P-value Yes (n=11) No (n=103) P-value Yes (n=33) No (n=81) P-value
    Socio-demographic characteristics and underlying diseases
     Age (yr) 60 (44–70) 43 (22–58) 63 (53–71) 0.000 43 (21–59) 62 (52–71) 0.001 40 (23–58) 62 (47–71) 0.009 41 (23.5–58) 60.5 (44.25–70) 0.000
     Female 48 (42.2) 15 (60.0) 33 (33.6) 0.023 15 (62.5) 33 (36.7) 0.023 8 (72.7) 40 (38.8) 0.065 22 (66.7) 26 (32.1) 0.001
     Low socio-economic level 53 (46.5) 12 (48.0) 41 (46.0) 0.600 15 (62.5) 38 (42.2) 0.077 4 (36.4) 49 (42.2) 0.479 19 (57.6) 34 (42.0) 0.131
     Primary school level 86 (75.4) 15 (60.0) 71 (79.7) 0.090 17 (70.8) 69 (76.7) 0.555 6 (54.5) 80 (77.7) 0.135 22 (66.7) 64 (79.0) 0.165
     No occupation 42 (36.8) 9 (36.0) 33 (37.1) 0.900 10 (41.7) 32 (35.6) 0.581 4 (36.4) 38 (36.9) 1.000 13 (39.4) 29 (35.8) 0.718
     Married 92 (80.7) 17 (68.0) 75 (84.3) 0.125 15 (62.5) 77 (85.6) 0.024 7 (63.6) 85 (82.5) 0.220 22 (66.7) 70 (86.4) 0.015
     Smoking 56 (49.12) 11 (44.0) 45 (50.6) 0.717 8 (33.3) 48 (53.3) 0.082 4 (36.4) 52 (50.5) 0.373 11 (33.3) 45 (55.6) 0.031
     Alcohol consumption 13 (11.4) 6 (24.0) 7 (7.8) 0.029 4 (16.7) 9 (10.0) 0.468 2 (18.2) 11 (10.7) 0.612 6 (18.2) 7 (8.6) 0.259
     CCI 1 (1–2) 1 (0–1) 1 (1–2) 0.043 1 (0–3) 1 (1–2) 0.004 1 (0–1) 1 (1–2) 0.165 1 (0–1) 1 (1–2) 0.002
     SAPS II 25 (17–31) 18.5 (14–27) 27 (18–32) 0.043 21 (14–26) 27 (18–32) 0.125 15 (13–24) 26 (18–32) 0.031 19 (13–26.5) 25.5 (16.75–31.25) 0.005
    Reasons for ICU admission NA NA NA NA
     Respiratory distress 79 (69.3) 17 (68) 62 (69.7) 16 (66.7) 63 (70.0) 6 (54.5) 73 (70.9) 21 (63.6) 58 (71.6)
     Shock 9 (7.9) 2 (8) 7 (7.9) 2 (8.3) 7 (7.8) 1 (9.1) 8 (7.8) 3 (9.1) 6 (7.4)
     Neurological disorder 7 (6.1) 2 (8) 5 (5.6) 2 (8.3) 5 (5.6) 0 7 (6.8) 2 (6.1) 5 (6.2)
     Metabolic disorders 7 (6.1) 2 (8) 5 (5.6) 2 (8.3) 5 (5.6) 0 7 (6.8) 3 (9.1) 4 (4.9)
     Sepsis 5 (4.4) 0 5 (5.6) 0 5 (5.6) 0 5 (4.9) 0 5 (6.2)
     Toxic exposures/poisoning 5 (4.4) 2 (8) 3 (3.4) 2 (8.3) 3 (3.3) 4 (36.4) 1 (1.0) 4 (12.1) 1 (1.2)
     Miscellaneous conditions 2 (1.8) 0 2 (2.2) 0 2 (2.2) 0 2 (1.9) 0 2 (2.5)
    Intensive care unit course
     NIV 71 (62.2) 13 (52.0) 58 (65.2) 0.356 14 (58.3) 57 (63.3) 0.653 4 (36.4) 67 (65.0) 0.124 16 (48.5) 55 (67.9) 0.052
     IMV 47 (41.2) 18 (72.0) 29 (32.6) 0.000 18 (75.0) 29 (32.2) 0.000 8 (72.7) 39 (37.9) 0.056 23 (69.7) 24 (29.6) 0.000
     Sedative use 47 (41.2) 19 (72.0) 28 (31.5) 0.000 18 (75.0) 29 (32.2) 0.000 8 (72.7) 39 (37.9) 0.056 23 (69.7) 24 (29.6) 0.000
     Catheterization 33 (29.0) 14 (56.0) 19 (21.3) 0.002 13 (54.2) 20 (22.5) 0.002 5 (45.5) 28 (27.5) 0.369 16 (48.5) 17 (21.0) 0.004
     Physical restraint 39 (34.2) 18 (72.0) 21 (23.6) 0.000 17 (70.8) 22 (24.4) 0.000 7 (63.6) 32 (31.1) 0.044 22 (66.7) 17 (21.0) 0.000
    Complication
     CIPNM 9 (7.9) 7 (28.0) 2 (2.2) 0.000 5 (20.8) 4 (4.4) 0.019 3 (27.3) 6 (5.8) 0.024 7 (21.2) 2 (2.5) 0.001
     VAP 14 (12.3) 7 (28.0) 7 (7.8) 0.013 6 (25.0) 8 (8.9) 0.074 3 (27.3) 11 (10.7) 0.134 8 (24.2) 6 (7.4) 0.030
     Pressure ulcers 7 (6.1) 3 (12.0) 4 (4.5) 0.160 2 (8.3) 5 (5.6) 0.637 2 (18.2) 5 (4.9) NA 3 (4.9) 4 (4.9) 0.418
    Outcome (day)
     Length of IMV 0 (0–4) 4 (1–9) 0 (0–2) 0.000 4 (1–8) 0 (0–3) 0.000 2 (0–6) 0 (0–3) 0.043 3 (0–6) 0 (0–4) 0.000
     Length of stay 6 (4–10) 7 (4–15) 6 (4–10) 0.099 6 (4–14) 6 (4–10) 0.270 6 (3–10) 6 (4–10) 0.650 6 (3.5–14) 6 (4–10) 0.551
    Variable Prefinal model
    		 Final model
    Crude OR (95% CI) Adjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value
    PTSD Age 0.947 (0.921–0.973) 2.755 (0.489–15.53) 0.002 0.95 (0.92–0.98) 0.001
    Female sex 3.167 (1.257–7.98) 4.751 (1.214–18.597) 0.025 3.88 (1.08–13.96) 0.038
    Physical restraint 8.327 (3.061–22.652) 5.778 (1.512–22.08) 0.010 6.27 (1.66–23.67) 0.007
    CIPNM 16.917 (3.244–88.207 9.702 (1.273–73.945) 0.028 11.15 (1.55–80.08) 0.017
    Alcohol consumption 3.699 (1.115–12.272) 2,755 (0.489–15.530) 0.251 - -
    Anxiety Married 0.281 (0.102–0.776) 0.275 (0.069–1.091) 0.066 0.20 (0.05–0.74) 0.016
    CCI 0.434 (0.232–0.813) 0.474 (0.233–0.963) 0.039 0.44 (0.22–0.89) 0.022
    Physical restraint 7.506 (2.753–20.464) 11.925 (3.48–40.861) 0.000 10.70 (3.26–35.17) 0.000
    Female sex 2.879 (1.135–7.303) 2.694 (0.827–8.772) 0.100 - -
    Depression Age 0.955 (0.922–0.988) 0.955 (0.903–1.037) 0.032 0.95 (0.91–0.985) 0.006
    CIPNM 6.062 (1.271–28.914) 9.371 (1.583–55.467) 0.014 8.46 (1.53–46.70) 0.014
    SAPS II 0.941 (0.882–0.99) 0.967 (0.903–1.037) 0.346 - -
    PICS-ND Age 0.914 (0.308–0.965) 0.937 (0.906–0.969) 0.000 0.938 (0.907–0.970) 0.000
    Female sex 4.231 (1.788–10.009) 8.087 (2.133–30.666) 0.001 7.980 (2.183–29.178) 0.002
    Physical restraint 7.529 (3.062–18.518) 11.680 (2.816–48.449) 0.000 17.637 (4.585–67.85) 0.000
    CIPNM 10.653 (2.207–54.427) 5.362 (0.726–39.583) 0.100 - -
    Table 1. Baseline characteristics and univariate analysis of factors associated with mental health outcomes in ICU survivors at 3 months post-discharge

    Values are presented as median (interquartile range) or number (%). Probability (p): comparison between the two groups (Wilcoxon-Mann-Whitney test for continuous data and chi-square test for categorical data).

    ICU: intensive care unit; PTSD: post-traumatic stress disorder; PICS-ND: post-intensive care syndrome–related neuropsychiatric disorders; CCI: Charlson Comorbidity Index; SAPS: Simplified Acute Physiological Score; NA: not applicable; NIV: non-invasive ventilation; IMV: invasive mechanical ventilation; CIPNM: critical illness polyneuropathy and myopathy; VAP: ventilatory-acquired pneumonia.

    Table 2. Binary logistic regression analysis for factors independently associated with mental health outcomes: crude and adjusted odds ratios from prefinal and final models

    OR: odds ratio; PTSD: post-traumatic stress disorder; CIPNM: critical illness polyneuropathy and myopathy; CCI: Charlson Comorbidity Index; SAPS: Simplified Acute Physiological Score; PICS-ND: post-intensive care syndrome–related neuropsychiatric disorders.

    Table 1.

    Table 2.

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