There is a high prevalence of patients with psychiatric disorders in intensive care units (ICUs), who may have a range of organic and psychopathological disorders.1 In addition, many ICU patients develop new psychiatric disorders or experience a worsening of existing ones. Therefore, appropriate psychopharmacological management is essential to reduce the psychopathological consequences associated with ICU stays in these patients.2

In recent years, the treatment and prevention of delirium in ICUs has become a central issue in patient care. Previous studies have associated delirium and poor mental health with an increased risk of mortality, longer hospital stays, extended ICU stays, and additional days on mechanical ventilation.3–5 Furthermore, delays in treatment may be associated with increased mortality.6 Thus, the recognition and treatment of delirium has resulted in an increased use of antipsychotics and tools for its detection in ICUs.7 Although antipsychotics may reduce delirium in ICUs, they may not reduce mortality.8 These medications may also be used for longer than necessary, even outside the hospital, increasing the risk of polypharmacy and adverse events.9 It is common for antipsychotic treatment, once initiated, to continue beyond the context for which it was prescribed.10,11

Patients with delirium or agitation may also be started on benzodiazepines, opioids, or sedative anticonvulsants. These factors make delirium a major contributor to polypharmacy at hospital discharge, particularly in critically ill older adults.

The progressive aging of the population, the optimisation of chronic disease management leading to longer survival, and the use of more aggressive therapies in elderly patients contribute to an increase in the number of elderly patients admitted to ICUs and, consequently, medication-related problems.

The prolonged use of antipsychotics after hospital admission may be associated with serious safety issues in older adults with dementia,12,13 which can increase short-term mortality,13 adverse drug effects, and the risk of readmission.14

There is little research on how often treatment is continued after ICU discharge after patients develop delirium during their stay, but available data suggest rates ranging from 23% to 50%.15,16

Flurie et al.15 assessed the continuation of antipsychotic therapy during transitions in care, finding that approximately 25% of patients who started antipsychotics in ICUs continued them after transfer to the medical ward, and of these, 39% continued them at hospital discharge. The CAM-ICU score is a test designed to detect confusional states and is based on a series of questions and instructions that is routinely administered in the ICU setting. This test was negative in about 65% of patients who continued therapy after ICU discharge.

Benzodiazepines are used in ICUs to treat agitation, alcohol deprivation symptoms, and to induce deep sedation. There is increasing evidence that the prolonged use of high doses of benzodiazepines, mainly midazolam and lorazepam, is associated with worsening delirium, morbidity, mechanical ventilation time, and ICU stay. Although their use is declining, they remain the most commonly used sedatives, with midazolam being the most widely used.17

The incidence of depression in critically ill patients, is not known with certainty, but estimates in these patients range from 10% to 30% depending on the disease and age.18,19 The percentage can reach 40% in critically ill geriatric patients when adjustment disorders, depressive symptoms secondary to the use of certain drugs, and the underlying disease itself are considered.18 This condition is commonly underdiagnosed by intensivists and has a negative impact on medium- and long-term prognosis. Pre-ICU depression is an important factor contributing to post-ICU depression.20 Weinert and Winterman studied the incidence of major depression (MD) and the use of pharmacological treatments in patients with acute respiratory failure. Within 2&#¿;months of ICU discharge, the incidence of MD was 28% and the prevalence of antidepressant medication use was 49%.21

Nearly 1 in 5 patients with chronic critical illness will experience an episode of MD up to 6&#¿;months after prolonged mechanical ventilation in ICUs.22 The implementation of programmes for rational drug use in critical care units may reduce the rates of therapy continuation at discharge, thereby reducing possible associated adverse effects. In this sense, D'angelo et al. were able to reduce the rates of antipsychotic therapy continuation at ICU discharge (27.9% vs 17.7%) after implementing a multidisciplinary training programme that included recommendations for the effective use of antipsychotics in delirium and an algorithm for their early discontinuation.23

Psychotropic drugs initiated during ICU stay are commonly continued after ICU discharge. The aim of this study is to analyse and measure the frequency with which psychotropic drugs initiated in the ICU are continued after discharge and to assess their contribution to patient polypharmacy. It also aims to lay the groundwork for the design of a potential future intervention to reduce polypharmacy related to these medications.

This protocol was developed in accordance with the international guidelines for the development and publication of research protocols (SPIRIT Guidelines).24

Delirium affects a large proportion of patients admitted to ICUs and may contribute to the development of anxiety disorders, post-traumatic stress disorder, and long-term major depressive disorder in patients who experience it.1–3

In addition to delirium, there are other reasons why a patient may be started on psychotropic drug treatment, such as psychosis. It is common for patients' psychological state to worsen both during and after their ICU stay.2

Antipsychotics have traditionally been used in the treatment of delirium in ICUs to control agitation and associated psychotic symptoms. However, their use should be carefully considered and a short and targeted approach is recommended.

Although previous studies have investigated the impact of the psychotropic prescriptions initiated in the ICU on different care transitions,13,21 to date, research is very scarce and there are no data on what is happening in Spain.

All these aspects highlight the need to know how these drugs are being used in the ICU setting, so that, if necessary, an educational intervention can be implemented a posteriori to reduce their use and the impact of their prescription.

On behalf of the Intensive Care and Critical Care Pharmacists Working Group (FARMIC) of the Spanish Society of Hospital Pharmacy (SEFH), we would like to publish the protocol for the PSICU-ALTA study, an observational study on the continuation of psychotropic drugs at ICU discharge, funded by the Spanish Foundation for Hospital Pharmacy (FEFH) in the 2023–2024 Working Group Grants Call. This is a national, multicentre study designed to analyse and measure the use of psychotropic drugs initiated during ICU admission, to raise awareness of patient polypharmacy, and to lay the groundwork for the design of a potential future intervention to reduce it.

This work has not been previously presented at any congress or scientific meeting, has not been previously published, and is not currently under review by any other journal. It has not received any prizes or citations.

The study has been evaluated and approved as an observational drug study (prospective) by the Ethics Committee for Medicines Research (CEIM) of the Vall d'Hebron University Hospital on 29 September 2023 (promoter code PSICU-ALTA). All collaborating researchers will sign an undertaking guaranteeing compliance with the Standards of Good Clinical Practice and the Declaration of Helsinki. Given the observational nature of the noninterventional study, a waiver of informed consent was approved. The confidentiality and anonymity of the information obtained regarding the patients, professionals, and ICUs involved will be guaranteed at all times, ensuring compliance with Organic Law 3/2018, of 5 December, on Personal Data Protection and guarantee of digital rights. The results of the study will not impose or entail any obligations on professionals or patients, but there is still a commitment to publish both positive and negative results.

The project was accepted and included in the funding of the Convocatoria de Ayudas a los Grupos de Trabajo de la Sociedad Española de Farmacia Hospitalaria 2023–2024.

The artificial intelligence tool ChatGPT was used to assist with the English translation of the abstract.

Laura Doménech-Moral: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Conceptualization. Javier Santader-Reboreda: Writing – review & editing, Writing – original draft, Validation, Investigation, Funding acquisition, Conceptualization. Meri Martin-Cerezuela: Writing – review & editing, Writing – original draft, Validation, Supervision, Software, Funding acquisition. Amaia Egüés Lugea: Writing – review & editing, Writing – original draft, Validation, Software, Funding acquisition. Marcos Buj Vicente: Writing – review & editing, Writing – original draft, Conceptualization. Sofía Contreras Medina: Writing – review & editing, Writing – original draft, Methodology, Conceptualization.