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Introduction

Psychiatric disorders, while mainly impacting mental health, can lead to severe physical complications that require admission to an intensive care unit (ICU). The connection between psychiatric and medical conditions often complicates diagnosis and treatment, especially when somatic symptoms overlap with or mask psychiatric manifestations.

Mental health and physical health are closely interconnected: mental illnesses can elevate the risk of developing physical conditions, while the existing medical problems can exacerbate psychiatric symptoms. Individuals with severe mental illness face a substantially higher risk of developing chronic conditions such as cardiovascular disease, diabetes, respiratory illness and certain cancers. Factors such as reduced physical activity, poor nutrition, medication side effects and barriers to healthcare access contribute to this elevated risk⁽¹⁾.

On the other hand, people living with chronic physical health problems experience depression and anxiety at approximately twice the rate of the general population, often due to the emotional and psychological strain of managing a long-term illness⁽²⁾. When mental and physical disorders occur together, they can create a cycle of worsening symptoms, diminished the quality of life, with prolonged recovery times, increased healthcare utilization and poorer overall health outcomes.

Patients with psychiatric disorders may require ICU admission for a variety of reasons, most commonly related to self-harm, substance overdose or acute medical complications. Intentionally self-poising, frequently involving psychotic medications such as benzodiazepines, antidepressants or antipsychotics, represents a major cause of ICU transfer from psychiatric wards, often necessitating airway protection and hemodynamic stabilization^(3,4). 

Substance overdoses, particularly involving alcohol, opioids or stimulants, can result in respiratory depression cardiac arrhythmias, seizures or severe automatic instability, that could also lead to an ICU transfer^(5,6).

Acute medical decompensations, including respiratory failure cardiovascular events and metabolic crises, are often linked to the direct effects of psychiatric medications, comorbid chronic diseases or unhealthy lifestyle factors⁽⁷⁾.

Among these causes, delirium secondary to substance withdrawal, particularly alcohol withdrawal delirium, remains one of the most critical and frequent indications for ICU admission in psychiatric population. Alcohol withdrawal delirium, or delirium tremens, typically develops 48-72 hours after a significant reduction or suddenly stopping of prolonged heavy alcohol intake⁽⁸⁾. It is marked by severe agitation, confusion, disorientation, hallucinations, autonomic hyperactivity and, in severe forms, seizures or cardiovascular collapse⁽⁹⁾. Without prompt recognition and intensive treatment, delirium tremens carries a high mortality risk which can be significantly reduced through early benzodiazepine administration, electrolyte correction, thiamine supplementation and continuous cardiorespiratory monitoring^(9,10).

What makes things even more challenging is that some psychiatric presentation can mask or coexist with somatic decompensation. An English qualitative study conducted in the emergency departments of four London general hospitals revealed that “diagnosis overshadowing” is a phenomenon that frequently occurs, where physical illness in psychiatric inpatients is misattributed to their mental disorder⁽¹¹⁾.

This misattribution can delay recognition of acute medical deterioration, particularly when symptoms such as agitation, confusion or behavioral change are assumed to be purely psychiatric in origin. In reality, these manifestations may indicate serious underlying conditions including delirium, infection, metabolic disturbances or hypoxia – that require urgent intervention^(12,13). Failure to promptly identify and treat these medical causes not only prolongs recovery, but can also increase morbidity and mortality in this vulnerable patient group.

ICU transfer itself carries significant implications for mental health, both in the short and long term. Survivors of critical illness frequently develop post-intensive care syndrome (PICS), a mix of new or worsening problems with physical health, memory and emotional well-being that can persist for months to years after discharge. Psychiatric disorders are common and include anxiety, depression and post-traumatic stress disorder (PTSD). The mechanisms are multifactorial, involving delirium, sedation, sleep disruption, feelings of helplessness and frightening ICU memories⁽¹⁴⁾.

That is why post-ICU rehabilitation is important to regain physical strength, restore cognitive function and support emotional recovery. Follow-up programs, which combine physical therapy, occupational therapy and psychological support, can help address the effects of post-intensive care syndrome. Evidence indicates that structured rehabilitation and early psychological screening following critical illness can significantly reduce the prevalence of post-ICU mental health complications⁽¹⁵⁾.

The aim of this study is to investigate the demographic, clinical and outcome profiles of psychiatric inpatients transferred to and from the intensive care unit in a Romanian hospital.  By analyzing 41 cases over a three-year period, the study explores the primary triggers for ICU transfer and the influence of age, sex and comorbidities on transfer patterns and outcomes.

Materials and method

This retrospective observational study included adult psychiatric inpatients (≥18 years old) who experienced at least one transfer to the intensive care unit (ICU) between January 2022 and December 2024 at Mureș County Emergency Hospital, Romania. Eligible cases were identified through hospital admission records from the psychiatric ward and ICU.

Data were extracted from electronic and paper medical charts, including demographics (age, sex, residential area), primary psychiatric and medical diagnoses, comorbidities, reason for ICU transfer, psychiatric history and discharge status.

For statistical analysis, categorical variables were compared using the Chi-square test to assess associations between demographic factors, psychiatric diagnoses, transfer causes and outcomes. The statistical significance was set at p

Ethical approval for this study was obtained from the hospital’s Ethics Committee, and all procedures complied with institutional and national research guidelines.

Results

A total of 41 adult psychiatric inpatients met the inclusion criteria, each experiencing at least one ICU transfer between January 2022 and December 2024. Of these 41 patients, 32% were female, and 63% were male. The mean age at transfer was roughly 63 years old, ranging from 19 to 87 years old. This single summary statistic tells us that the cohort is predominantly represented by older adults, which aligns with typical critical-care populations where comorbidities and physiologic reserve become major concerns.

Regarding place of residence, slightly more than half of the patients (54%; n=22) resided in urban areas, followed by 27% (n=11) from rural areas, and 19% (n=8) from suburban locations.

The chart illustrates the distribution of the primary psychiatric diagnosis in the patient sample. Alcohol withdrawal syndrome with or without delirium is the most frequent diagnosis, accounting for 46% of cases. This indicates that alcohol-related disorders represent a major proportion of the psychiatric pathology observed, comprising almost half of the total cases. Additionally, there were three secondary diagnoses also related to alcohol use, further emphasizing the impact of alcohol-related conditions in this cohort.

Dementia (Alzheimer’s, unspecified) is the second most common diagnosis, at 23%, highlighting a significant presence of neurocognitive disorders in the studied population.

Major depressive syndrome accounts for 10% of cases, showing that severe affective disorders are present, but not as dominant as substance-related or cognitive decline disorders.

Acute psychotic episode represents 5% of cases, a relatively small, yet important share in the context of psychiatric emergencies.

The category “Others” (16%) includes single cases from a wide range of diagnoses: moderate intellectual disability, anxiety disorders, cluster B personality disorder, paranoid schizophrenia, persistent delusional disorder and psychomotor agitation possibly associated with COVID-19.

In the analyzed cohort, a statistically significant association was found between sex and alcohol-related diagnoses (χ²(1)=4.50; p=0.034). Male patients were considerably more likely to have alcohol-related psychiatric disorders compared to female patients.

Among the 41 patients analyzed, the most frequently observed psychiatric symptom was psychomotor agitation (33 patients; 80.5%), followed by temporo-spatial disorientation (29 patients; 70.7%), irritability (19 patients; 46.3%) and sleep-related problems (19 patients; 46.3%). Other symptoms included hallucinations (16 patients; 39%), anxiety (13 patients; 31.7%), tremor (12 patients; 29.3%), toxicophilic behavior (10 patients; 24.4%), paranoid delusions (eight patients; 19.5%) and aggression (six patients; 14.6%). Less frequent symptoms included bradypsychia and/or bradylalia (five patients; 12.2%), suspiciousness (four patients; 9.8%), suicidal ideation (four patients; 9.8%) and sweating (three patients; 7.3%). These results indicate that psychomotor and orientation disturbances were the most prevalent issues, while severe cognitive or behavioral disruptions occurred less often but still in a clinically relevant proportion of the sample.

On average, we identified 3-4 causes of transfer to the intensive care unit per patient. In total, 156 causes were recorded, with each occurrence counted individually. These causes were then grouped into seven main categories.

Neurological disorders/altered mental status accounted for the largest share of ICU transfer triggers. This group included a wide range of acute neurological and consciousness-related issues: acute or progressive confusion, altered consciousness, delirium and delirium tremens, deterioration, decreased consciousness, low GCS, poor or non-responsiveness, somnolence, drowsiness, seizures, swallowing dysfunction, uncooperative behavior and risk of respiratory depression.

Metabolic, renal or hepatic disorders were another major reason for transfer, comprising acute kidney injury (AKI), acute renal failure (ARF), dehydration (including severe dehydration and hypovolemia), electrolyte imbalances or disturbances (hypernatremia, hyponatremia, hyperkalemia), hepatic and renal dysfunction, hepatocellular injury, metabolic coma, renal dysfunction, feeding difficulty, laboratory abnormalities and worsening general condition.

Infections and septic complications included both localized and systemic infections: sepsis, pneumonia, bronchopneumonia, COVID-19, bacterial infections, meningoencephalitis, colitis, pansinusitis, encephalopathy, fever and inflammatory syndrome.

Vital instability encompassed acute hemodynamic compromise and cardiovascular emergencies, such as hemodynamic instability, hypotension, hypertensive crisis, tachycardia, tachypnea, cardiovascular instability, acute or systemic decompensation, acute cardiopulmonary decompensation, risk of hemodynamic collapse and cardiac arrest.

Respiratory failure and respiratory symptoms were also common precipitants of ICU transfer. These included respiratory distress, respiratory instability, hypoxia, hyperventilation, dyspnea, shallow abdominal breathing, respiratory symptoms and excessive sweating associated with acute respiratory compromise.

Toxic causes consisted of toxicological emergencies such as neuroleptic malignant syndrome, self-poisoning and suicide attempts with drugs.

Other acute causes included conditions such as multiorgan dysfunction, acute injury, acute adrenal insufficiency, low cortisol levels, abdominal distension, abdominal pain and vomiting, and each could precipitate rapid clinical deterioration, requiring ICU-level care.

Comorbidities were prevalent in this cohort, with cardiovascular disease, chronic liver disease and metabolic disorders being the most frequently recorded. Many patients had multiple comorbidities, which contributed to the complexity of their clinical course and increased the risk of medical deterioration.

The ICU length of stay among the 41 patients varied widely, ranging from less than three hours to six weeks. The median was five days (interquartile range: 2-10 days).

Short stays (

Intermediate stays (2-7 days) were the most common, observed in 26 patients (63.4%), reflecting the typical recovery period for acute medical decompensations or intoxications after stabilization.

Prolonged stays (>7 days) occurred in 11 patients (26.8%), most frequently in individuals with severe infections, multiorgan dysfunction or complex postoperative recovery.
The single longest stay (six weeks) was associated with a complicated medical course involving severe sepsis and prolonged ventilator support.

Regarding ICU outcomes, 71% (n=29) of patients showed clinical improvement and were discharged to a lower level of care, while 29% (n=12) died during hospitalization. A Chi-square test of independence did not reveal a significant association between being over 65 years old and the outcome (p>0.05), suggesting that in this sample, prognosis was not substantially influenced by belonging to an older age group.

Discussion

Regarding the age distribution in our cohort, older patients were more frequently transferred to the ICU, a finding consistent with previous evidence showing that advanced age is associated with a higher burden of medical comorbidities, reduced physiological reserve and greater vulnerability to acute decompensation. Studies such as those of Hendrie et al. (2013) have highlighted that elderly psychiatric patients often present with multiple chronic conditions – cardiovascular, metabolic and neurological – that can complicate psychiatric care and increase the chances of requiring critical care interventions⁽¹⁶⁾.

Although no significant association was found between age and outcome, older patients in the cohort tended to present with a higher burden of comorbidities, which can complicate management and potentially increase the risk of adverse events during hospitalization.

Heavy and chronic alcohol use is a major public health concern, as it increases both psychiatric vulnerability and the risk of severe medical emergencies. Among these, alcohol withdrawal delirium (delirium tremens) is a frequent cause of ICU admission from psychiatric wards, given its clinical severity and potential for respiratory, cardiovascular and neurological decompensation⁽¹⁷⁾. In Romania, where structured detox and early intervention resources may be limited, the risk for ICU-level complications is further amplified.

In our study, the majority of patients had alcohol-related psychiatric diagnoses, most commonly alcohol withdrawal syndrome with or without delirium. The high predominance can be explained by Romania’s elevated alcohol consumption which, according to World Health Organization, was 12.6 liters of pure alcohol per adult in 2019 compared with a European regional average of 9.2 liters⁽¹⁸⁾. This level of intake increases the risk of alcohol-related disorders and their medical complications.

In our cohort, there was a statistically significant association between sex and alcohol-related psychiatric diagnoses (p=0.017), with male patients being disproportionately affected. This aligns with national and international epidemiological data indicating that men in Romania consume more alcohol than women, both in frequency and volume⁽¹⁷⁾. The higher prevalence of harmful drinking patterns among men translates into an increased incidence of alcohol withdrawal syndromes requiring hospital care and, in severe cases, ICU admission.

Recent evidence, however, indicates that, although men continue to consume more alcohol than women, the gender gap in alcohol use is gradually getting smaller over recent decades. This trend has been observed in multiple populations, with younger cohorts showing smaller differences in drinking patterns compared to older generations. Such shifts are thought to reflect changing social norms, greater gender equality in social participation, and evolving attitudes toward alcohol use^(19,20).

As expected, the ten most prevalent symptoms observed in our ICU cohort – psychomotor agitation, disorientation, sleep disturbances, irritability, hallucinations, confusion, tremor, toxicophilic behavior, paranoid delusions and aggression – are highly consistent with the neuropsychiatric profile of acute alcohol withdrawal complicated by delirium, as well as delirium occurring in patients with underlying cognitive impairment or dementia, which were among the two most frequent diagnoses in our study^(18,21).

In our study, the most frequent precipitating factors for ICU transfer were neurological disorders and altered mental status (22.4%), followed closely by metabolic, renal or hepatic disorders (19.9%) and infectious or septic complications (16%). Neurological deterioration –acute or progressive confusion, delirium (including delirium tremens), decreased consciousness, seizures – and other consciousness-related symptoms emerged as the leading trigger for ICU admission. This is consistent with literature showing that acute brain failure, whether due to primary neurological disease or to secondary systemic causes, is a common and urgent reason for critical care intervention, especially in patients with preexisting cognitive vulnerability^(22,23).

Metabolic, renal and hepatic complications were the second most common cause, encompassing acute kidney injury, severe electrolyte disturbances, hepatic dysfunction and metabolic coma. These conditions are well-recognized precipitants of both systemic instability and acute neuropsychiatric syndromes such as delirium, particularly in the context of multimorbidity and polypharmacy⁽²⁴⁾. Infectious and septic complications, notably sepsis, pneumonia, COVID-19 and meningoencephalitis, contributed significantly to ICU transfers in our cohort, aligning with evidence that systemic infections frequently precipitate delirium and acute functional decline in vulnerable populations.

Other important triggers included vital instability (13.5%), such as acute hemodynamic collapse, hypertensive crisis, arrhythmias and respiratory failure (10.3%), representing severe complications that require management in the ICU. Toxic causes (2.6%), including neuroleptic malignant syndrome and drug intoxication, though less frequent, carried high morbidity and required urgent ICU-level monitoring.

In our cohort, all patients who died during ICU admission (n=12) presented with severe acute illness on the background of multiple chronic conditions. Cardiovascular comorbidities (such as hypertension, arrhythmia and ischemic heart disease) were the most prevalent, frequently associated with renal dysfunction (acute renal failure, chronic kidney disease and metabolic acidosis) and hepatic disease (hepatitis, chronic toxic liver disease and hepatocytolysis). Neurological disorders, including dementia, encephalopathy, epilepsy and Alzheimer’s disease, were also common, while infectious complications (COVID-19, sepsis, pneumonia and bronchopneumonia) often contributed to deterioration. On average, the deceased patients had between six and eight comorbidities, highlighting the substantial burden of chronic disease in this group.

Limitations and future directions

This study encountered several limitations, including a relatively small, single-center sample and the retrospective design, which depends on the accuracy of clinical documentation and may have led to underreporting of symptoms or comorbidities. 

In addition, the overlap of psychiatric and medical manifestations in patients with severe multimorbidity complicates the identification of the main drivers of ICU admission or mortality.

In the future, larger multicenter studies with standard psychiatric evaluations and post-discharge follow-up could help better understand recovery patterns and guide strategies to prevent acute decompensation in high-risk psychiatric patients.

Conclusions

In our study, 41 psychiatric inpatients required ICU transfer over a three-year period, representing a relatively small number, but a clinically complex group. The most frequent triggers for transfer were neurological deterioration, metabolic and hepatic dysfunction and systemic infections, which often occurred together and increased patient vulnerability. Delirium was common, usually related to alcohol withdrawal or superimposed on dementia, and often presented with agitation, disorientation and confusion. Many of the patients who died had multiple chronic comorbidities and multiorgan failure, highlighting how fragile this population is. These findings underline the importance of early recognition of deterioration, careful management of chronic conditions and the close collaboration between psychiatric and medical teams to improve patient outcomes.    

Corresponding author: Camelia Sandu E-mail: sandu_camy@yahoo.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.