50 CHAPTER 3 after discharge.4 Similar to findings in the current study, there was a large overlap between mental health problems (63% experienced a combination of anxiety, depression, or trauma-related symptoms), supporting the use of a mental frailty framework. A second study among 629 patients found that close to a third was suffering from symptoms of anxiety, followed by PTSD and depression at 3-months after discharge.5 Despite a rather large variation in the percentage of patients with mental health problems and heterogeneity in distribution of symptoms, the current study confirms that mental frailty is common in ICU-survivors. The general assumption is that a psychiatric history before admission and presence of delirium during admission make patients more vulnerable for long-termmental morbidity.24 However, current data suggest that these factors have a limited impact on the odds for mental frailty when including mental health parameters to the prediction model. Previous studies confirmed the lack of association between psychiatric history, delirium, and long-term mental health.4,25 Our model identified higher depression scores at 3-months as a strong predictor for long-termmental frailty. These findings suggest that using psychological screening tools for depression, among others, may be an effective screening tool formental frailty in the post-critical illness rehabilitation setting. In addition, including sub-clinical depression scores in post-ICU assessments of recovery may be necessary to properly identify patients in need of aftercare as symptoms in patients with frailty may worsen over the year. Long-term mental frailty has far-reaching consequences for the patient and their informal caregivers. In this study, patients with mental frailty scored significantly lower on several domains of HRQoL, namely mental health, problems in role functioning due to emotional problems, energy/fatigue, and social functioning. Specifically in the domains of role functioning and energy/ fatigue patients with mental frailty did not match age-adjusted reference values.16 In addition, patients that were experiencingmental frailty at 12-months scored higher on emotional coping at both time points, which may be an interesting finding to explore further in future research. The difference in coping may also be a contributing factor of our finding that mental frailty was correlated with higher caregiver burden and caregiver trauma symptoms. At both 3 and 12-months, a fifth of caregivers indicated unhealthy levels of strain. Although the subjects of caregiver burden and PICS-Family (PICS-F) are still underrepresented in medical outcome research, a study of 94 relatives of ICU-survivors found similar results.9 Additional studies found a correlation between impaired HRQoL of the patient and caregiver burden.26,27 These
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