Barriers and opportunities for implementation of a brief psychological intervention for post-ICU mental distress in the primary care setting – results from a qualitative sub-study of the PICTURE trial
Authors: Sanftenberg Linda , Beutel Antina , Friemel Chris Maria , Kosilek Robert Philipp , Schauer Maggie , Elbert Thomas , Reips Ulf-Dietrich , Gehrke-Beck Sabine , Schubert Tomke , Schmidt Konrad , Gensichen Jochen ,   for the PICTURE-study team, Adrion Christine , Angstwurm Matthias , Bergmann Antje , Bielmeier Gerhard , Bischhoff Andrea , Bogdanski Ralph , Brettner Franz , Brettschneider Christian , Briegel Josef , Bürkle Martin , Dohmann Johanna , Falkai Peter , Felbinger Thomas , Fisch Richard , Förstl Hans , Fohr Benjamin , Franz Martin , Friederich Patrick , Friemel Chris Maria , Gallinat Jürgen , Gerlach Herwig , Güldner Andreas , Hardt Hanna , Heintze Christoph , Heinz Andreas , Heller Axel , von Heymann Christian , Hoppmann Petra , Huge Volker , Irlbeck Michael , Jaschinski Ulrich , Jarczak Dominik , Joos Stefanie , Kaiser Elisabeth , Kerinn Melanie , Klefisch Frank-Rainer , Kluge Stefan , Koch Roland , Koch Thea , Kowalski Michelle , König Hans-Helmut , Lackermeier Peter , Laugwitz Karl-Ludwig , Lemke Yvonne , Lies Achim , Linde Klaus , Lindemann Daniela , Lühmann Dagmar , May Stephanie , Ney Ludwig , Oltrogge Jan , Pankow Wulf , Papiol Sergi , Ragaller Maximilian , Rank Nikolaus , Reill Lorenz , Richter Hans-Peter , Riessen Reimer , Ringeis Grit , Rüchhardt Ann , Schelling Gustav , Schelling Jörg , Scherag André , Scherer Martin , Schneider Antonius , Schneider Gerhard , Schneider Jürgen , Schnurr Julia , Schultz Susanne , Schulze Thomas G , Schumacher Karin , Spieth Peter , Thurm Franka , Vogl Thomas , Voigt Karen , Walther Andreas , Wassilowsky Dietmar , Wäscher Cornelia , Weber-Carstens Steffen , Wehrstedt Regina , Weierstall-Pust Roland , Weis Marion , Weiss Georg , Well Harald , Zöllner Christian , Zwissler Bernhard 
Published: May 2023

Abstract
Background
The results of critical illness and life-saving invasive measures during intensive care unit treatment can sometimes lead to lasting physical and psychological impairments. A multicentre randomized controlled trial from Germany (PICTURE) aims to test a brief psychological intervention, based on narrative exposure therapy, for post-traumatic stress disorder symptoms following intensive care unit treatment in the primary care setting. A qualitative analysis was conducted to understand feasibility and acceptance of the intervention beyond quantitative analysis of the main outcomes in the primary study.

Methods
Qualitative explorative sub-study of the main PICTURE trial, with eight patients from the intervention group recruited for semi-structured telephone interviews. Transcriptions were analysed according to Mayring's qualitative content analysis. Contents were coded and classified into emerging categories.

Results
The study population was 50% female and male, with a mean age of 60.9 years and transplantation surgery being the most frequent admission diagnosis. Four main factors were identified as conducive towards implementation of a short psychological intervention in a primary care setting: 1) long-term trustful relationship between patient and GP team; 2) intervention applied by a medical doctor; 3) professional emotional distance of the GP team; 4) brevity of the intervention.

Conclusion
The primary setting has certain qualities such as a long-term doctor-patient relationship and low-threshold consultations that offer good opportunities for implementation of a brief psychological intervention for post-intensive care unit impairments. Structured follow-up guidelines for primary care following intensive care unit treatment are needed. Brief general practice-based interventions could be part of a stepped-care approach.

Trial registration
The main trial was registered at the DRKS (German Register of Clinical Trials: DRKS00012589) on 17/10/2017.