CHEST Original Research

CRITICAL CARE

Self-reported Depressive Symptoms

and Memory Complaints in Survivors
Five Years After ARDS
Neill K. J. Adhikari, MDCM; Catherine M. Tansey, PhD; Mary Pat McAndrews, PhD;
Andrea Matté, BSc; Ruxandra Pinto, PhD; Angela M. Cheung, MD, PhD;
Natalia Diaz-Granados, MSc; and Margaret S. Herridge, MD, MPH

Background: Survivors of ARDS report depressive symptoms and memory complaints, the preva-
lence of which after 5 years is unknown.
Methods: We administered instruments assessing symptoms of depression (Beck Depression
Inventory II [BDI-II]) and memory complaints (Memory Assessment Clinics Self-Rating Scale
[MAC-S]) to 64 survivors of ARDS from four university-affiliated ICUs 5 years after ICU dis-
charge. We compared BDI-II scores to quality of life (Medical Outcomes Study 36-Item Short
Form [SF-36]) mental health domains (role emotional, mental health, mental component summary),
compared BDI-II and MAC-S scores to earlier scores (median, 22 months postdischarge), and
examined return to work.
Results: Forty-three (67.2%), 46 (71.9%), and 38 (59.4%) patients fully completed the BDI-II,
MAC-S ability subscale, and MAC-S frequency of occurrence subscale, respectively. Responders
were young (median, 48 years; first-third quartile [Q1-Q3], 39-61 years) with high illness severity.
The median BDI-II score was 10 (Q1-Q3, 3-18); eight of 43 (18.6%) had moderate to severe
depressive symptoms compared with 14 of 43 (32.6%) earlier (P 5 .15, n 5 38 with paired data).
Median MAC-S ability and MAC-S frequency scores were 81 (Q1-Q3, 57-92) and 91.5 (Q1-Q3,
76-105), respectively, similar to earlier scores (P 5 .67 and P 5 .64, respectively); 0% to 4.3%
scored . 2 SDs below population norms. Higher BDI-II score was predicted by higher earlier
BDI-II score, slower recovery of organ function, and longer duration of mechanical ventilation
and ICU stay. Higher MAC-S score was predicted by higher earlier MAC-S score. SF-36 men-
tal health domain scores were very stable (P 5 .57-.83). BDI-II and SF-36 mental health domains
were negatively correlated (Spearman coefficient, 20.50 to 20.82). Most patients returned to work
regardless of depressive symptoms (minimal to mild, 31 of 35 [88.6%]; moderate to severe, five
of eight [62.5%]; P 5 .12).
Conclusions: Compared with ⵑ 2 years postdischarge from the ICU, depressive symptoms and
memory complaints were similar at 5 years. Mental health domains of the SF-36 may not be sen-
sitive to small changes in mood symptoms. CHEST 2011; 140(6):1484–1493

Abbreviations: BDI-II 5 Beck Depression Inventory-II; MAC-S 5 Memory Assessment Clinics Self-Rating Scale;
MCS 5 mental component summary; MH 5 mental health; Q1-Q3 5 first-third quartile; RE 5 role emotional;
SF-36 5 Medical Outcomes Study 36-Item Short Form

P atients with acute lung injury have respiratory fail-

ure with hypoxemia (more severe in the subgroup
with ARDS), bilateral pulmonary infiltrates that are
not due to left atrial hypertension, and an identifi-
able risk factor.1 The estimated annual incidence is
nearly 200,000 cases in the United States,2 and the
case fatality rate is 35% to 45%.3 Current evidence
suggests that survivors have persistent generalized
weakness,4 reduced quality of life,5 significant cogni-
tive impairment,6 and psychiatric morbidity7 compared
with the general population.
We followed survivors of ARDS enrolled in a
5-year cohort study.4,8,9 In a previous report, we
described a high prevalence (41%) of moderate to
severe depressive symptoms and a lower prevalence
(8% to 20%, depending on the threshold used) of
memory complaints in this cohort at a median of
22 months (range, 6-48 months) after discharge from

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© 2011 American College of Chest Physicians
the ICU.10 Furthermore, patients reporting moderate
to severe depressive symptoms were less likely to
return to work than those with minimal to mild symp-
toms. In the current study, our objectives were to
(1) evaluate the prevalence of depressive symp-
toms and memory complaints in the same group of
survivors of ARDS at 5 years after ICU discharge;
(2) identify ICU predictors of depressive symptoms
and memory complaints; and (3) examine the associ-
ation between depressive symptom severity and return-
to-work outcomes.
Materials and Methods
Patients
The patients in this study participated in a prospective cohort
study of survivors of ARDS enrolled at four University of Toronto-
affiliated ICUs between May 1998 and May 2001.4,8,9 Eligible
patients were aged ⱖ 16 years, had a Pao2/Fio2 ratio of ⱕ 200
while receiving mechanical ventilation, with a positive end-
expiratory pressure of ⱖ 5 cm H2O; airspace changes in all four
quadrants on chest radiography; and an identifiable risk factor for
ARDS. Patients were excluded if they were immobile prior to
ICU admission, had a history of lung resection, or had a neuro-
logic disease or psychiatric disorder documented in their chart.
We obtained informed consent for questionnaire completion. The
University Health Network Research Ethics Board approved this
study (98-H015).
Survey Administration and Outcomes
We administered the Beck Depression Inventory II (BDI-II)11
and Memory Assessment Clinics Self-Rating Scale (MAC-S)12-14
to patients twice: (1) by mail at a median of 22 months (range,
Manuscript received July 3, 2011; revision accepted September 19,
2011.
Affiliations: From the Interdepartmental Division of Critical
Care (Drs Adhikari and Herridge), University of Toronto, Toronto;
Department of Critical Care Medicine (Drs Adhikari and Pinto),
Sunnybrook Health Sciences Centre, Toronto; Department of
Medicine (Drs Tansey, Cheung, and Herridge and Ms Matté),
Krembil Neuroscience Centre (Dr McAndrews), and Women’s
Health Program (Dr Cheung and Ms Diaz-Granados), University
Health Network, Toronto; Department of Medicine (Drs Cheung
and Herridge) and Department of Health Policy, Management
and Evaluation and the Dalla Lana School of Public Health
(Dr Cheung), University of Toronto, Toronto; and Department of
Clinical Epidemiology and Biostatistics (Ms Diaz-Granados),
McMaster University, Hamilton, ON, Canada.
Funding/Support: This work was performed at the University of
Toronto and was supported by Physicians’ Services Incorporated,
Ontario Thoracic Society, and Canadian Intensive Care Founda-
tion. Dr Cheung is supported by a Canadian Institutes of Health
Research Senior Investigator Award and the Lillian Love Chair
in Women’s Health at the University of Toronto and University
Health Network.
Correspondence to: Neill K. J. Adhikari, MDCM, Department
of Critical Care Medicine, Room D1.08, Sunnybrook Health
Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5,
Canada; e-mail: neill.adhikari@utoronto.ca
© 2011 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians (http://www.chestpubs.org/
site/misc/reprints.xhtml).
DOI: 10.1378/chest.11-1667
www.chestpubs.org
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© 2011 American College of Chest Physicians
6-48 months) following ICU discharge10 and (2) in person at
follow-up 5 years after ICU discharge. We also administered
the Medical Outcomes Study 36-Item Short Form (SF-36)15 in
person during annual postdischarge visits. Study personnel or
family members helped to administer the instruments for patients
who needed assistance (eg, translation for non-English readers).
Self-reported psychiatric diagnoses after hospital discharge are
reported elsewhere.9
The BDI-II instrument screens for depression using criteria
consistent with the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, with higher scores (range, 0-63) indi-
cating more severe depressive symptoms. There are two subscales
measuring cognitive (nine items) and somatic-affective (12 items)
symptoms,11 a factor structure validated in medical patients.16,17
Based on testing in psychiatric outpatients, symptom severity is
classified as minimal (score of 0-13), mild (14-19), moderate (20-28),
or severe (29-63).
The MAC-S instrument measures self-reported performance
in daily memory tasks, and is divided into the ability subscale
(21 items probing the ability to remember specific types of infor-
mation) and frequency of occurrence subscale (24 items asking
about the frequency of particular memory problems). Higher
scores (range for ability, 21-105; range for frequency of occur-
rence, 24-120) indicate better performance.
The SF-3615,18,19 measures health-related quality of life in
eight domains, including role emotional (RE) (limitations in usual
role activities because of emotional problems) and general mental
health (MH), with each domain scored from 0 (worst quality of
life) to 100 (best). The mental component summary (MCS)20 is
an aggregate score. The SF-36 has Canadian population-based
norms21 and has been used in critically ill patients.22,23
Statistical Analysis
For descriptive data, we summarized nonnormally distrib-
uted continuous data using medians (first-third quartile [Q1-Q3])
and compared groups using Wilcoxon rank sum tests. Categor-
ical data were summarized as proportions and compared using
x2 or Fisher exact tests. We compared 5-year and earlier scores
using Wilcoxon signed rank test for continuous variables and
exact McNemar test (because of small cell sizes) for catego-
rized scores, including patients who contributed data at both
times. We used Spearman correlation to measure the correlation
between instruments (BDI-II cognitive vs somatic-affective sub-
scales; BDI-II vs MAC-S subscales; BDI-II and subscales vs each
mental health domain of SF-36). We excluded questionnaires with
any missing items from all analyses but included them when
describing respondent baseline characteristics.
We were interested in hypothesis-generating analyses of pre-
dictors of 5-year BDI-II and MAC-S scores, including a priori
selected baseline and ICU variables. We tested each potential
predictor in a univariable linear regression analysis and in a
model adjusting for the earlier BDI-II or MAC-S score and
time between questionnaire administrations. For the BDI-II
models, we log-transformed all BDI-II scores and two predictor
variables (days of mechanical ventilation and ICU stay) to ensure
normally distributed residuals. We log-transformed the same two
predictor variables for the MAC-S models because their distri-
butions were skewed but did not transform the MAC-S scores. For
the MAC-S adjusted analyses, we excluded cases with high resid-
uals (n 5 1 for ability subscale and n 5 3 for frequency subscale) to
ensure stability of the estimates of the regression coefficients.
We conducted two sensitivity analyses. The first explored the
effects of missing data by including questionnaires with , 50%
missing items and calculating an adjusted score based on items
answered as follows: (total possible score for all items 3 score for
items answered)/maximum possible score for items answered.
CHEST / 140 / 6 / DECEMBER, 2011 1485
The second explored the effects of including the three cases with
high residuals in the MAC-S frequency regression models.
We analyzed the relationship between moderate to severe
vs minimal to mild depressive symptoms (defined by 5-year
BDI-II scores) and (1) return to any work and (2) return to pre-
vious position (both at 5 years). Any work included paid and
unpaid work inside or outside the home. Because of small cell
sizes (n , 5) in two-by-two tables, we used exact methods to gen-
erate ORs, 95% CIs, and P values. All statistical tests were two
sided; we interpreted P , .05 as statistically significant. Analyses
were conducted using SAS, version 9.2 (SAS Institute Inc; Cary,
North Carolina) statistical software.
Results
Study Participants
We enrolled 109 survivors of ARDS in the cohort,
of whom 21 died and 24 were lost to follow-up by the
time of the 5-year evaluation9 (Fig 1). Of 74 known
survivors at 5 years, 64 patients were evaluated, of
whom 46 (71.9%) returned the BDI-II, 47 (73.4%)
returned the MAC-S, and 48 (75.0%) returned either
one. A median of 41 months (Q1-Q3, 32.5-52 months)
separated the two questionnaire administrations.10
Responders were similar to nonresponders (Table 1);
they were relatively young (median age, 48 years;
Q1-Q3, 39-61 years), and most were men (52.1%),
spoke English as a first language (66.7%), and had
some postsecondary education (60.5%). Responders
had a high APACHE (Acute Physiology and Chronic
Health Evaluation) II score,24 maximum multiple
organ dysfunction score,25 maximum lung injury
score,26 and persistently limited 6-min walk distance
(median, 79% predicted; Q1-Q3, 60%-89% predicted).
Instrument Scores and Correlations
Of the 64 survivors evaluated, 43 (67.2%), 46 (71.9%),
and 38 (59.4%) patients fully completed the BDI-II,
MAC-S ability subscale, and MAC-S frequency of
occurrence subscale, respectively. Linear regression
Figure 1. Study flow. BDI-II 5 Beck Depression Inventory II;
MAC-S 5 Memory Assessment Clinics Self-Rating Scale.
1486
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© 2011 American College of Chest Physicians
analyses of change in instrument scores vs months
between the two administrations showed no signifi-
cant associations (e-Figure 1). Histograms of scores
on each instrument are presented in Figure 2.
The median BDI-II score at 5 years was 10
(Q1-Q3, 3-18), similar to earlier scores (P 5 .11).
Using BDI-II-defined categories, 35 respondents
(81.4%) reported minimal or mild depressive symp-
toms and eight (18.6%) reported moderate or severe
symptoms. There was no significant difference
(P 5 .15) in the number of patients in the moderate
to severe category at 5 years. Cognitive and somatic-
affective subscale scores were highly correlated
(Spearman correlation coefficient, 0.77; P , .001).
Scores on the MAC-S instrument were 81 (Q1-Q3,
57-92) for the ability subscale and 91.5 (Q1-Q3,
76-105) for the frequency of occurrence subscale and
were unchanged from earlier scores (ability, P 5 .67;
frequency, P 5 .64). Relative to a US community-
based sample,12,13 4.3% of respondents in the ability
subscale and none in the frequency subscale scored
lower than 2 SDs below age-adjusted norms. These
proportions increased to 8.7% and 15.2% (ability
subscale) and 10.5% and 10.5% (frequency subscale),
with cut points of 1.5 SDs and 1 SD, respectively
(Table 2). BDI-II scores were moderately negatively
correlated with MAC-S scores (Spearman correlation
coefficient, 20.62 and 20.76 for ability and frequency
of occurrence subscales, respectively; P , .0001),
implying an association between increasing symptoms
of depression and lower memory scores (ie, more
memory complaints).
Patients in this sample had SF-36 scores of 100
(Q1-Q3, 66.7-100) for RE, 78 (Q1-Q3, 60-92) for
MH, and 52 (Q1-Q3, 39-58) for MCS. Relative to a
Canadian population sample,21 13.6%, 8.7%, and
14.0% scored more than 2 SDs below age-adjusted
norms for these domains. These percentages rose
to 27.3%, 28.3%, and 27.9%, respectively, with a cut
point of 1 SD. Correlations between BDI-II (total
score and cognitive and somatic-affective subscales)
and SF-36 (RE, MH, and MCS) were moderately
to highly negative (Table 3).
Unadjusted analyses (Tables 4, 5) demonstrated
no demographic or illness severity associations with
BDI-II or MAC-S scores. In adjusted analyses, higher
earlier BDI-II or MAC-S scores consistently pre-
dicted higher 5-year scores. A more positive multiple
organ dysfunction score slope (ie, slower recovery
of organ function), longer duration of mechanical
ventilation, and longer ICU stay were associated with
higher BDI-II scores (ie, more severe depressive
symptoms). A more positive lung injury score slope
(ie, slower recovery of lung injury) had a similar
effect, but statistical significance was borderline. For
BDI-II, sensitivity analyses that included adjusted
Original Research
 Table 1—Characteristics of Survivors of ARDS

Variable Responders (n 5 48) Nonresponders (n 5 16) P Value

Age at follow-up, y 48 (39-61) 54 (46-63) .17
Female sex 23 (47.9) 8 (50) .89
Primary language English 32 (66.7) 8 (50) .23
Education
High school or less 19 (39.6) 8 (53.3) .65
Some college 15 (31.3) 3 (20.0)
University degree 14 (29.2) 4 (26.7)
APACHE II score 23 (15-28)a 22 (17-28) .96
Maximum LIS during ICU admissionb 3.8 (3.3-4.0) 3.5 (3.0-4.0) .098
Maximum MODS during ICU admission 12 (10.5-13.5) 11 (9-12) .12
ICU length of stay, d 27.5 (17-51) 22.5 (14.5-34.5) .19
Time since ICU discharge to current questionnaire, mo 62 (61-64) 61 (60-63) .45
Time since ICU discharge to earlier questionnaire, mo 22 (11-29) … …
Time between previous and current questionnaire completion, moa 41 (32.5-52) … …
6-min walk distance at 5-y clinic visit
Distance, m 454 (366-512)c 367 (249-429)d .14
% Predicted 79 (60-89)c 69 (44-83)d .29
Data are presented as median (first-third quartile) or No. (%). The 48 responders returned either a BDI-II or MAC-S questionnaire. APACHE 5 Acute
Physiology and Chronic Health Evaluation; BDI-II 5 Beck Depression Inventory II; LIS 5 Lung Injury Score; MAC-S 5 Memory Assessment
Clinics Self-Rating Scale; MODS 5 Multiple Organ Dysfunction Score.
an 5 47.

bThe LIS included the sum of the chest radiography, hypoxemia, and positive end-expiratory pressure scores, while excluding static compliance.

cn 5 45.

dn 5 9.

scores for questionnaires with missing items gave
similar results. Female sex was associated with a
lower MAC-S ability score (ie, more severe memory
complaints) in an adjusted analysis, but the effect dis-
appeared in a sensitivity analysis that included ques-
tionnaires with missing data. In a sensitivity analysis
for MAC-S frequency of occurrence that included
the three cases with high residuals, the adjusted anal-
ysis also showed a significant effect of female sex, but
this effect was no longer significant if questionnaires
with missing items were included.
Depressive Symptoms and Return to Work
Most patients returned to work at 5 years. Of
35 patients with minimal to mild depressive symp-
toms, 31 (88.6%) had returned to any work, and
30 (85.7%) had returned to their previous position.
Of eight patients with moderate to severe symptoms
of depression, five (62.5%) had returned to any work,
and four (50.0%) had returned to their previous posi-
tion. Patients with moderate to severe vs minimal to
mild depressive symptoms tended to be less likely to
return to any work (OR, 0.23; 95% CI, 0.03-1.53;
P 5 .12) or their previous position (OR, 0.18; 95% CI,
0.03-1.01; P 5 .051), but the results were not statisti-
cally significant.
Discussion
This study included 48 relatively young patients
with high illness severity and no documented psychi-
atric illness who survived ARDS and answered
questionnaires assessing depressive symptoms and
memory complaints 5 years after ICU discharge. We
found that depressive symptoms at 5 years were sim-
ilar compared with ⵑ 2 years after ICU discharge.
The SF-36 mental health domains (MH, RE, and
MCS), although correlated with BDI-II at 5 years,
were completely stable between assessments and
may lack sensitivity to small, but clinically impor-
tant changes in mood in survivors of critical illness.
Memory complaints were reported by 0% to 15.2%
of patients, depending on the domain (ability or
frequency of occurrence) and threshold used to
define a deficit; the proportion was similar at the ear-
lier assessment. Given the small numbers, it is diffi-
cult to draw definitive conclusions regarding depressive
symptoms and return to work, but the majority
returned to the workforce in some capacity, even
with continuing symptoms. The most consistent pre-
dictor of scores on each instrument at 5 years was the
earlier score. Adjusted analyses also found that slower
resolution of multiple organ dysfunction and longer
duration of ICU stay and mechanical ventilation may
be associated with worse depressive symptoms at
5 years. Interestingly, slower resolution of multiple
organ dysfunction and lung injury also may be asso-
ciated with a shorter 6-min walk distance in these
patients.9
Other studies evaluating depressive symptoms
earlier after ICU discharge have reported similar
findings. A systematic review reported a median point

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Figure 2. Histograms of BDI-II (n 5 43), MAC-S ability subscale (n 5 48), and MAC-S frequency of occurrence subscale (n 5 38).
Categories represent 10-point bins and only include questionnaires with no missing items. See Figure 1 legend for expansion of
abbreviations.

prevalence of clinically significant depression of 28%
(range, 17%-43%) in four studies of survivors of ARDS,
using various instruments administered within ⵑ 2 years
of ICU discharge.7 Factors related to subsequent
severity of depressive symptoms included days in ICU,
days of mechanical ventilation, and days of seda-
tion27; surgical vs trauma or medical diagnosis28; alcohol
dependence; female sex and younger age29; admis-
sion to surgical vs medical or trauma ICU and more
organ dysfunction30; and higher daily ICU benzodi-
azepine dose.31 Hopkins et al29 found that depression
in survivors of ARDS at 1 year after hospital dis-
charge (16% of survivors), along with the presence
of cognitive sequelae, predicted depression at 2 years
(23% of survivors). Taken together, these observations
suggest that the prevalence of depressive symptoms
in survivors of ARDS remains relatively stable over
time, thus justifying a program of active and ongoing
psychiatric surveillance.
Studies32-39 performing formal neurocognitive
testing (assessing mental processing speed, memory,
attention, problem-solving [executive function],
intellectual function, and visual-spatial ability) after
ARDS generally have found a higher prevalence
of impairments compared with the prevalence of
memory complaints that we reported earlier10 and in
the present study. As we noted previously,10 this dis-
cordance has been noted in other populations and
may arise from the presence of more severe objective
memory impairment than patients perceived or poor
correlation of self-reported memory complaints with
objective testing.40-49 Others have found no consis-
tent associations among baseline clinical variables,
illness severity, and postdischarge neurocognitive
dysfunction.6
To our knowledge, no other study has measured
self-reported depressive symptoms or memory com-
plaints using validated instruments in critically ill
patients 5 years after ICU discharge in a well-
characterized inception cohort. The major strength
of the present study is the reliable ascertainment of
exposure variables (baseline status and selected ICU
treatment and physiologic variables) and outcomes
(symptoms of depression and memory complaints).
Our study also has weaknesses. Of the 74 survivors of
ARDS at 5 years, 10 (13.5%) were lost to follow-up
and 64 (86.5%) were evaluated in the clinic, but only
48 (64.9%) attempted to complete BDI-II or MAC-S

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 Table 2—Depressive Symptoms and Memory Function in Survivors of ARDS

Outcome Earlier (ⵑ 2 y) 5y P Value (No.)

BDI-II (n 5 43, n 5 43)a 11 (3-25) 10 (3-18) .11 (38)

Depressive symptom severity (n 5 43, n 5 43)b .15 (38)
Minimal (0-13) 24 (55.8) 29 (67.4)
Mild (14-19) 5 (11.6) 6 (14.0)
Moderate (20-28) 8 (18.6) 3 (7.0)
Severe (29-63) 6 (14.0) 5 (11.6)
MAC-S
Ability (n 5 42, n 5 46)c 75.5 (61-94) 81 (57-92) .67 (40)
Comparison with normative sampled
, 2 SDs 2 (4.8) 2 (4.3) 1.00
, 1.5 SDs 5 (11.9) 4 (8.7) 1.00
, 1 SD 6 (14.3) 7 (15.2) 1.00
Frequency (n 5 42, n 5 38)e 91 (76-105) 91.5 (76-105) .64 (33)
Comparison with normative sampled
, 2 SDs 2 (4.8) 0 (0) 1.00
, 1.5 SDs 2 (4.8) 4 (10.5) .50
, 1 SD 7 (16.7) 4 (10.5) 1.00
SF-36 100 (33.3-100) 100 (66.7-100) .83 (36)
RE (n 5 39, n 5 44)f
Comparison with normative sampleg
, 2 SDs 7 (18.0) 6 (13.6) 1.00
, 1.5 SDs 9 (23.1) 9 (20.5) 1.00
, 1 SD 11 (28.2) 12 (27.3) 1.00
MH (n 5 40, n 5 46)f 78 (64-88) 78 (60-92) .57 (38)
Comparison with normative sampleg
, 2 SDs 6 (15) 4 (8.7) 1.00
, 1.5 SDs 6 (15) 5 (10.9) 1.00
, 1 SD 10 (25) 13 (28.3) .73
MCS (n 5 38, n 5 43)f 51 (42-57.5) 52 (39-58) .74 (34)
Comparison with normative sampleg
, 2 SDs 5 (13.2) 6 (14.0) 1.00
, 1.5 SDs 8 (21.1) 8 (18.6) 1.00
, 1 SD 9 (23.7) 12 (27.9) .45
Data are presented as median (first-third quartile) or No. (%). Percentages may not sum to 100% because of rounding. The two n values in the first
column refer to the earlier questionnaires (completed at a median of 22 months [range, 6-48 months] following ICU discharge for BDI-II and
MAC-S10 and 2 y for SF-36) and the 5-y questionnaires, respectively. Of 64 survivors evaluated at 5 y, 48 patients answered either the BDI-II or the
MAC-S; data for the earlier time point includes only patients who also completed the 5-y questionnaires. Comparisons between 5-y and earlier
scores were made using Wilcoxon signed rank test (continuous variables) and exact McNemar test (categorized scores) and only included patients
who contributed data at both time points. MCS 5 mental component summary; MH 5 mental health; RE 5 role emotional; SF-36 5 Medical
Outcomes Study 36-Item Short Form. See Table 1 legend for expansion of other abbreviations.
aAt 5 y (n 5 48), two patients did not answer BDI-II, and three had missing items; at the earlier administration, two did not answer, and three had

missing items.
bDepression categories are from the BDI-II scale. The P value refers to the comparison of minimal to mild vs moderate to severe categories at

5 y vs the earlier assessment.

cAt 5 years (n 5 48), one patient did not answer, and one had a missing item; at the earlier administration, one did not answer, and five had missing

items.
dProportion of sample , 2, , 1.5, or , 1 SD below age-adjusted US sample mean.14 We used patients’ ages at questionnaire completion.

eAt 5 y (n 5 48), one patient did not answer, and nine had missing items; at the earlier assessment, one did not answer, and fi ve had missing

items.
fAt 5 y (n 5 48), one patient did not answer, and three, one, and four patients had missing items for RE, MH, and MCS, respectively. At the earlier

assessment, eight patients did not answer, and one and two patients had missing items for RE and MCS, respectively.
gProportion of sample , 2, , 1.5, or , 1 SD below age- and sex-matched Canadian sample mean.21 We used patients’ ages at questionnaire

completion.

questionnaires. Because the sample size was small,
the power to detect clinically important differences
between responders and nonresponders was limited.
In other studies evaluating quality of life ⱖ 5 years
after ICU discharge, rates of follow-up of known sur-
vivors were 48.0%,50 62.5%,51 66.0%,52 and 91.1%.53
The present nonresponse rate of approximately one-
third of survivors is, therefore, similar to several other
studies. However, subsequent biases in instrument
responses are unpredictable because the direction of
confounding due to clinically dissimilar baseline char-
acteristics between responders and nonresponders

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Table 3—Agreement Between BDI-II and SF-36 Mental impairments and mood disorders. We did not col-
Health Domains lect data on other possible predictors of BDI-II
Spearman and MAC-S, such as medications, hypoxemia,32,35,36
Variable No. Correlation (95% CI) P Value hypoglycemia,54 or environmental issues in the ICU,
BDI-II vs SF-36 RE 40 20.64 (20.79, 20.41) , .0001
or intervening events between ICU discharge and
BDI-II vs SF-36 MH 42 20.82 (20.90, 20.69) , .0001 questionnaire administration. We excluded patients
BDI-II vs SF-36 MCS 39 20.68 (20.82, 20.46) , .0001 with psychiatric disorders documented in their med-
BDI-II (cognitive) 41 20.50 (20.70, 20.23) .0007 ical chart but did not formally assess premorbid cog-
vs SF-36 RE nitive function or mood. We did not screen for other
BDI-II (cognitive) 43 20.78 (20.88, 20.63) , .0001
vs SF-36 MH
mood disorders, delirium, or dementia or conduct
BDI-II (cognitive) 40 20.64 (20.79, 20.41) , .0001 standardized psychiatric interviews. Finally, the rela-
vs SF-36 MCS tionship between the subjective instruments we used
BDI-II (somatic-affective) 41 20.65 (20.80, 20.43) , .0001 and objective neurocognitive testing and diagnosis of
vs SF-36 RE major depressive disorder is unclear and requires
BDI-II (somatic-affective) 43 20.79 (20.88, 20.64) , .0001
further research.
vs SF-36 MH
BDI-II (somatic-affective) 40 20.66 (20.81, 20.44) , .0001 In summary, patients who survive ARDS to 5 years
vs SF-36 MCS after discharge have similar scores on instruments
See Table 1 and 2 legends for expansion of abbreviations. assessing depressive symptoms and self-reported
memory complaints compared with ⵑ 2 years after
ICU discharge. Future studies should evaluate these
may be unknown or inconsistent. In addition, we long-term trends in different populations along with
likely had low power to detect clinically important concurrent postdischarge mental health utilization
associations between questionnaire scores and the (medication use, visits to mental health providers,
variables examined. and hospitalization), which would enhance under-
Other weaknesses of the study are unchanged.10 standing of the trajectory of these symptoms. Screening
The sample consists of relatively young and employed for depressive symptoms should use specific validated
patients with few comorbidities at the time of critical instruments rather than the mental health domains of
illness, and the findings may not be generalizable to a general health-related quality-of-life instrument,
older and sicker survivors of critical illness who may such as the SF-36. Descriptions of these phenomena
be expected to have more severe long-term memory and their impact on quality of life in observational

Table 4—Predictors of Log-Transformed BDI-II Score at Five Years in Univariable Analyses

Adjusted for Earlier Score and Time

Unadjusted Between Scores

Variable b (SE) P Value b (SE) P Value

APACHE II 0.034 (0.024) .17 0.022 (0.024) .36
Female sex 0.54 (0.39) .18 0.61 (0.38) .12
Age 20.016 (0.013) .24 20.013 (0.012) .31
Maximum MODS 0.081 (0.066) .23 0.10 (0.059) .11
Slope of MODSa 0.43 (0.29) .15 0.76 (0.26) .006
Maximum LIS 0.073 (0.48) .88 0.082 (0.46) .86
Slope of LISb 0.24 (0.23) .30 0.42 (0.21) .06
Steroid use 0.19 (0.41) .65 0.59 (0.39) .14
ICU daysc 0.35 (0.26) .19 0.58 (0.24) .02
Mechanical ventilation daysc 0.38 (0.25) .13 0.61 (0.23) .01
Any muscle relaxants 0.086 (0.42) .84 0.13 (0.40) .74
High-frequency ventilation 0.31 (0.41) .46 0.56 (0.43) .20
Predictor variables refer to the index ICU admission (except for age, which is at the time of questionnaire administration). Unadjusted analyses
included questionnaires with no missing items (n 5 43 except for APACHE II [n 5 42]). Separately for each predictor, we also included the earlier
BDI-II score and the number of months between BDI-II administrations (n 5 38 except for APACHE II [n 5 37]) in an adjusted analysis. All BDI-II
scores were log-transformed. We added 0.5 to 0 scores before taking the logarithm (n 5 4 at 5 y in unadjusted analyses; n 5 3 at 5 y and n 5 3
for the earlier questionnaire in adjusted analyses). Positive (negative) b coefficients imply that the predictor is associated with higher (lower) log-
transformed BDI-II scores. In adjusted analyses, b values for the earlier BDI-II score ranged from 0.39 to 0.46 and were highly significant
(P 5 .003-.015); b values for the time between administrations were small and not statistically significant. In sensitivity analyses calculating adjusted
scores for questionnaires with missing items, results are similar. See Table 1 and 2 legends for expansion of abbreviations.
aThe change in MODS over time during ICU admission is expressed as the slope of the score.

bThe change in LIS over time during ICU admission is expressed as the slope of the score.

cThe logarithm of this variable was used because the untransformed variable had a skewed distribution.

1490 Original Research

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© 2011 American College of Chest Physicians
 Table 5—Predictors of MAC-S at Five Years in Univariable Analyses

Adjusted for Earlier Score and Time

Unadjusted Between Scores

Variable b (SE) P Value b (SE) P Value

Ability subscalea

APACHE II 20.56 (0.39) .16 0.05 (0.22) .82

Female sex 27.50 (5.82) .20 28.12 (3.04) .01
Age 20.16 (0.19) .41 0.12 (0.11) .29
Maximum MODS 20.36 (1.02) .72 20.18 (0.55) .75
Slope of MODSb 21.25 (4.52) .78 21.72 (3.15) .59
Maximum LIS 0.62 (6.98) .93 0.47 (3.82) .90
Slope of LISc 24.87 (3.58) .18 23.37 (2.57) .20
Steroid use 25.95 (6.13) .34 23.78 (3.27) .26
ICU daysd 21.51 (4.01) .71 22.82 (2.27) .22
Mechanical ventilation daysd 21.78 (3.83) .64 22.60 (2.19) .24
Any muscle relaxants 22.33 (6.29) .71 4.83 (3.33) .16
High-frequency ventilation 24.15 (6.01) .49 22.31 (3.57) .52
Frequency of occurrence subscalee
APACHE II 20.037 (0.46) .94 0.25 (0.23) .28
Female sex 212.11 (6.23) .06 22.26 (3.67) .54
Age 0.16 (0.21) .45 0.10 (0.10) .33
Maximum MODS 0.68 (1.13) .55 0.36 (0.62) .57
Slope of MODSb 6.10 (5.53) .28 23.28 (3.01) .29
Maximum LIS 4.69 (7.83) .55 0.63 (3.89) .87
Slope of LISc 4.56 (4.71) .34 1.91 (2.48) .45
Steroid use 20.58 (6.82) .93 22.63 (3.51) .46
ICU daysd 2.84 (4.41) .52 21.21 (2.31) .60
Mechanical ventilation daysd 1.80 (4.23) .67 21.07 (2.19) .63
Any muscle relaxants 20.96 (6.96) .89 25.23 (4.00) .20
High-frequency ventilation 1.92 (6.55) .77 20.83 (3.69) .82
Predictor variables refer to the index ICU admission (except for age, which is at the time of questionnaire administration). Unadjusted analyses
include questionnaires with complete data (n 5 46 for ability subscale except for APACHE II [n 5 45]; n 5 38 for frequency of occurrence subscale).
Separately for each predictor, we also included the earlier MAC-S score and the number of months between MAC-S administrations in an adjusted
analysis. For the ability subscale, adjusted analyses (n 5 39 for all except APACHE II [n 5 38]) excluded one case with high residuals. For the
frequency of occurrence subscale, adjusted analyses (n 5 30) excluded three cases with high residuals. Positive (negative) b coefficients imply that
the predictor is associated with higher (lower) MAC-S scores. In adjusted analyses, b values for the earlier MAC-S score ranged from 0.84 to 0.94
and were highly significant (all P , .0001); b values for the time between administrations were small and not statistically significant. See Table 1 and
2 legends for expansion of abbreviations.
aIn a sensitivity analysis calculating adjusted scores for questionnaires with missing items, results were similar, but female sex was no longer

significant in the adjusted analysis.

bThe change in MODS over time during ICU admission is expressed as the slope of the score.

cThe change in LIS over time during ICU admission is expressed as the slope of the score.

dThe logarithm of this variable was used because the untransformed variable had a skewed distribution.

eIn a sensitivity analysis including the three cases with high residuals, the adjusted analyses showed a significant effect of female sex (b, 211.60;

SE, 4.60; P 5 .02). However, this effect was no longer significant if questionnaires with missing items were included by calculating adjusted scores.

studies has grown considerably in contrast to the
relative paucity of data from randomized trials of
interventions to improve postdischarge quality of
life.55 Therefore, development and evaluation of
feasible, reliable, and valid methods to screen survi-
vors of ARDS for psychiatric conditions and pro-
vide prompt referral to mental health expertise is
required.
Acknowledgments
Author contributions: Dr Adhikari had full access to all of the
data in the study and takes responsibility for the integrity of the
data and the accuracy of the data analysis.
Dr Adhikari: contributed the design of the analyses, interpreta-
tion of the data, and drafting and revision of the manuscript.
Dr Tansey: contributed to the data collection and revision of the
manuscript.
Dr McAndrews: contributed to the study design and revision of
the manuscript.
Ms Matté: contributed to the data collection, data entry, and revi-
sion of the manuscript.
Dr Pinto: contributed to the data analysis and revision of the
manuscript.
Dr Cheung: contributed to the study design and revision of the
manuscript.
Ms Diaz-Granados: contributed to the study design and revision
of the manuscript.
Dr Herridge: contributed to the study design and conception,
obtaining of funding, supervision, data collection and interpreta-
tion, and revision of the manuscript.
Financial/nonfinancial disclosures: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article.

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© 2011 American College of Chest Physicians
Role of sponsors: The sponsors had no role in the design of the
study, the collection and analysis of the data, or in the preparation
of the manuscript.
Additional information: The e-Figure can be found in the
Online Supplement at http://chestjournal.chestpubs.org/content/
140/6/1484/suppl/DC1.
References
1. Bernard GR, Artigas A, Brigham KL, et al. The American-
European Consensus Conference on ARDS. Definitions,
mechanisms, relevant outcomes, and clinical trial coordina-
tion. Am J Respir Crit Care Med. 1994;149(3 pt 1):818-824.
2. Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence
and outcomes of acute lung injury. N Engl J Med. 2005;
353(16):1685-1693.
3. Phua J, Badia JR, Adhikari NK, et al. Has mortality from
acute respiratory distress syndrome decreased over time? a
systematic review. Am J Respir Crit Care Med. 2009;179(3):
220-227.
4. Herridge MS, Cheung AM, Tansey CM, et al; Canadian
Critical Care Trials Group. One-year outcomes in survivors
of the acute respiratory distress syndrome. N Engl J Med.
2003;348(8):683-693.
5. Dowdy DW, Eid MP, Dennison CR, et al. Quality of life
after acute respiratory distress syndrome: a meta-analysis.
Intensive Care Med. 2006;32(8):1115-1124.
6. Hopkins RO, Jackson JC. Long-term neurocognitive func-
tion after critical illness. Chest. 2006;130(3):869-878.
7. Davydow DS, Desai SV, Needham DM, Bienvenu OJ.
Psychiatric morbidity in survivors of the acute respiratory
distress syndrome: a systematic review. Psychosom Med.
2008;70(4):512-519.
8. Cheung AM, Tansey CM, Tomlinson G, et al. Two-year
outcomes, health care use, and costs of survivors of acute
respiratory distress syndrome. Am J Respir Crit Care Med.
2006;174(5):538-544.
9. Herridge MS, Tansey CM, Matté A, et al; Canadian Critical
Care Trials Group. Functional disability 5 years after acute
respiratory distress syndrome. N Engl J Med. 2011;364(14):
1293-1304.
10. Adhikari NK, McAndrews MP, Tansey CM, et al. Self-
reported symptoms of depression and memory dysfunction
in survivors of ARDS. Chest. 2009;135(3):678-687.
11. Beck AT, Steer RA, Brown GK. Manual for the Beck
Depression Inventory-II. San Antonio, TX: Psychological
Corporation; 1996:1-38.
12. Winterling D, Crook T, Salama M, et al. A self-rating scale for
assessing memory loss. In: Bès A, Cahn J, Hoyer S, et al, eds.
Senile Dementias: Early Detection. London, England and
Paris, France: John Libbey Eurotext; 1986:482-487.
13. Crook TH III, Larrabee GJ. A self-rating scale for evaluating
memory in everyday life. Psychol Aging. 1990;5(1):48-57.
14. Crook TH, Larrabee GJ. Normative data on a self-rating
scale for evaluating memory in everyday life. Arch Clin
Neuropsychol. 1992;7(1):41-51.
15. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form
health survey (SF-36). I. Conceptual framework and item
selection. Med Care. 1992;30(6):473-483.
16. Arnau RC, Meagher MW, Norris MP, Bramson R. Psycho-
metric evaluation of the Beck Depression Inventory-II with
primary care medical patients. Health Psychol. 2001;20(2):
112-119.
17. Viljoen JL, Iverson GL, Griffiths S, Woodward TS. Factor
structure of the Beck Depression Inventory-II in a medical
outpatient sample. J Clin Psychol Med Settings. 2003;10(4):
289-291.
1492
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on December 7, 2011
© 2011 American College of Chest Physicians
18. McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item
Short-Form Health Survey (SF-36): II. Psychometric and
clinical tests of validity in measuring physical and mental
health constructs. Med Care. 1993;31(3):247-263.
19. McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD. The
MOS 36-item Short-Form Health Survey (SF-36): III. Tests
of data quality, scaling assumptions, and reliability across
diverse patient groups. Med Care. 1994;32(1):40-66.
20. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA,
Rogers WH, Raczek A. Comparison of methods for the
scoring and statistical analysis of SF-36 health profile and
summary measures: summary of results from the Medical
Outcomes Study. Med Care. 1995;33(suppl 4):AS264-AS279.
21. Hopman WM, Towheed T, Anastassiades T, et al; Canadian
Multicentre Osteoporosis Study Research Group. Canadian
normative data for the SF-36 health survey. CMAJ. 2000;
163(3):265-271.
22. Dowdy DW, Eid MP, Sedrakyan A, et al. Quality of life in
adult survivors of critical illness: a systematic review of the
literature. Intensive Care Med. 2005;31(5):611-620.
23. Winters BD, Eberlein M, Leung J, Needham DM,
Pronovost PJ, Sevransky JE. Long-term mortality and quality
of life in sepsis: a systematic review. Crit Care Med. 2010;
38(5):1276-1283.
24. Knaus WA, Draper EA, Wagner DP, Zimmerman JE.
APACHE II: a severity of disease classification system. Crit
Care Med. 1985;13(10):818-829.
25. Marshall JC, Cook DJ, Christou NV, Bernard GR,
Sprung CL, Sibbald WJ. Multiple organ dysfunction score:
a reliable descriptor of a complex clinical outcome. Crit
Care Med. 1995;23(10):1638-1652.
26. Murray JF, Matthay MA, Luce JM, Flick MR. An expanded
definition of the adult respiratory distress syndrome
[published correction appears in Am Rev Respir Dis. 1989;
139(4):1065]. Am Rev Respir Dis. 1988;138(3):720-723.
27. Nelson BJ, Weinert CR, Bury CL, Marinelli WA, Gross CR.
Intensive care unit drug use and subsequent quality of life
in acute lung injury patients. Crit Care Med. 2000;28(11):
3626-3630.
28. Myhren H, Ekeberg O, Tøien K, Karlsson S, Stokland O.
Posttraumatic stress, anxiety and depression symptoms in
patients during the first year post intensive care unit dis-
charge. Crit Care. 2010;14(1):R14.
29. Hopkins RO, Key CW, Suchyta MR, Weaver LK, Orme JF Jr.
Risk factors for depression and anxiety in survivors of acute
respiratory distress syndrome. Gen Hosp Psychiatry. 2010;
32(2):147-155.
30. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-
related Organ Failure Assessment) score to describe organ
dysfunction/failure. On behalf of the Working Group on
Sepsis-Related Problems of the European Society of Intensive
Care Medicine. Intensive Care Med. 1996;22(7):707-710.
31. Dowdy DW, Bienvenu OJ, Dinglas VD, et al. Are intensive
care factors associated with depressive symptoms 6 months
after acute lung injury? Crit Care Med. 2009;37(5):1702-1707.
32. Hopkins RO, Weaver LK, Pope D, Orme JF, Bigler ED,
Larson-LOHR V. Neuropsychological sequelae and impaired
health status in survivors of severe acute respiratory distress
syndrome. Am J Respir Crit Care Med. 1999;160(1):50-56.
33. Rothenhäusler HB, Ehrentraut S, Stoll C, Schelling G,
Kapfhammer HP. The relationship between cognitive perfor-
mance and employment and health status in long-term survi-
vors of the acute respiratory distress syndrome: results of an
exploratory study. Gen Hosp Psychiatry. 2001;23(2):90-96.
34. Jackson JC, Hart RP, Gordon SM, et al. Six-month neuro-
psychological outcome of medical intensive care unit patients.
Crit Care Med. 2003;31(4):1226-1234.
Original Research
35. Hopkins RO, Weaver LK, Chan KJ, Orme JF Jr. Quality of life,
emotional, and cognitive function following acute respiratory
distress syndrome. J Int Neuropsychol Soc. 2004;10(7):
1005-1017.
36. Hopkins RO, Weaver LK, Collingridge D, Parkinson RB,
Chan KJ, Orme JF Jr. Two-year cognitive, emotional, and
quality-of-life outcomes in acute respiratory distress syndrome.
Am J Respir Crit Care Med. 2005;171(4):340-347.
37. Hopkins RO, Jackson JC, Wallace CJ. Neurocognitive impair-
ments in ICU patients with prolonged mechanical ventilation
[abstract]. J Int Neuropsychol Soc. 2005;11(supp 1):60.
38. Jones C, Griffiths RD, Slater T, Benjamin KS, Wilson S.
Significant cognitive dysfunction in non-delirious patients
identified during and persisting following critical illness.
Intensive Care Med. 2006;32(6):923-926.
39. Mikkelsen ME, Shull WH, Biester RC, et al. Cognitive, mood
and quality of life impairments in a select population of ARDS
survivors. Respirology. 2009;14(1):76-82.
40. Baños JH, LaGory J, Sawrie S, et al. Self-report of cognitive
abilities in temporal lobe epilepsy: cognitive, psychosocial,
and emotional factors. Epilepsy Behav. 2004;5(4):575-579.
41. Carter SL, Rourke SB, Murji S, Shore D, Rourke BP. Cognitive
complaints, depression, medical symptoms, and their associ-
ation with neuropsychological functioning in HIV infection: a
structural equation model analysis. Neuropsychology. 2003;
17(3):410-419.
42. Duits A, Munnecom T, van Heugten C, van Oostenbrugge RJ.
Cognitive complaints in the early phase after stroke are
not indicative of cognitive impairment. J Neurol Neurosurg
Psychiatry. 2008;79(2):143-146.
43. Hilsabeck RC, Hassanein TI, Carlson MD, Ziegler EA,
Perry W. Cognitive functioning and psychiatric symptom-
atology in patients with chronic hepatitis C. J Int Neuropsychol
Soc. 2003;9(6):847-854.
44. Booth-Jones M, Jacobsen PB, Ransom S, Soety E. Characteristics
and correlates of cognitive functioning following bone
marrow transplantation. Bone Marrow Transplant. 2005;36(8):
695-702.
45. Klepstad P, Hilton P, Moen J, Fougner B, Borchgrevink PC,
Kaasa S. Self-reports are not related to objective assessments
www.chestpubs.org
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on December 7, 2011
© 2011 American College of Chest Physicians
of cognitive function and sedation in patients with cancer pain
admitted to a palliative care unit. Palliat Med. 2002;16(6):
513-519.
46. Mitchell AJ. The clinical significance of subjective memory
complaints in the diagnosis of mild cognitive impairment and
dementia: a meta-analysis. Int J Geriatr Psychiatry. 2008;
23(11):1191-1202.
47. Vogel A, Elberling TV, Hørding M, et al. Affective symptoms
and cognitive functions in the acute phase of Graves’ thyro-
toxicosis. Psychoneuroendocrinology. 2007;32(1):36-43.
48. Reid LM, Maclullich AM. Subjective memory complaints
and cognitive impairment in older people. Dement Geriatr
Cogn Disord. 2006;22(5-6):471-485.
49. Robinson JP, Burwinkle T, Turk DC. Perceived and
actual memory, concentration, and attention problems
after whiplash-associated disorders (grades I and II): prev-
alence and predictors. Arch Phys Med Rehabil. 2007;88(6):
774-779.
50. Cuthbertson BH, Roughton S, Jenkinson D, Maclennan G,
Vale L. Quality of life in the five years after intensive care:
a cohort study. Crit Care. 2010;14(1):R6.
51. Schelling G, Stoll C, Vogelmeier C, et al. Pulmonary function
and health-related quality of life in a sample of long-term sur-
vivors of the acute respiratory distress syndrome. Intensive
Care Med. 2000;26(9):1304-1311.
52. Kaarlola A, Pettilä V, Kekki P. Quality of life six years after
intensive care. Intensive Care Med. 2003;29(8):1294-1299.
53. Graf J, Wagner J, Graf C, Koch KC, Janssens U. Five-year
survival, quality of life, and individual costs of 303 consec-
utive medical intensive care patients—a cost-utility analysis.
Crit Care Med. 2005;33(3):547-555.
54. Dowdy DW, Dinglas V, Mendez-Tellez PA, et al. Intensive
care unit hypoglycemia predicts depression during early
recovery from acute lung injury. Crit Care Med. 2008;36(10):
2726-2733.
55. Cuthbertson BH, Rattray J, Campbell MK, et al; PRaCTICaL
study group. The PRaCTICaL study of nurse led, intensive
care follow-up programmes for improving long term outcomes
from critical illness: a pragmatic randomised controlled trial.
BMJ. 2009;339:b3723.
CHEST / 140 / 6 / DECEMBER, 2011 1493