The Hidden Costs of ICU Caregiving: Economic, Mental Health and Spiritual Consequences.

Background: Family caregivers of intensive care unit (ICU) patients face a double burden: the psychological toll of critical illness and the economic and occupational disruptions that often accompany prolonged caregiving. While prior research has examined caregiver distress, few studies have systematically integrated economic, psychological and spiritual domains over long-term follow-up. Methods: This study presents a cross-sectional analysis conducted at long-term follow-up examining economic, occupational, psychological, and spiritual correlates among family caregivers of former ICU patients. From an initial cohort of 189 caregivers, 92 participated in a five-year follow-up, completing validated psychometric instruments (SCL-90-R, SpREUK, CD-RISC-10, Heartland Forgiveness, F-COPES). Multivariate regression models were used to identify predictors of psychological and spiritual outcomes, while cluster analysis explored heterogeneity in caregiver profiles. Results: Job loss emerged as a strong predictor of anxiety and hostility, while reduced working hours showed a protective association against depression and anxiety. Financial burden was less consistently associated with psychopathology. Spirituality demonstrated an ambivalent pattern of correlational associations: while dimensions such as trust and reflection were linked to adaptive coping, higher levels of spiritual engagement were also associated with elevated depressive symptoms, suggesting a reactive rather than purely protective role. Resilience and coping resources (e.g., reframing, forgiveness, personal competence) mitigated distress, whereas neuroticism amplified vulnerability. Cluster analysis revealed three distinct caregiver subgroups: a high-burden cluster (severe psychopathology and economic strain), a moderate cluster with mixed spiritual and psychological engagement and a resilient cluster with minimal burden. Conclusions: This study highlights that economic stressors are not peripheral but central drivers of caregiver distress and that spirituality, although valued, may operate in both adaptive and maladaptive ways. Tailored interventions must integrate financial protection, psychological support and sensitive spiritual care to address the multidimensional reality of ICU caregiving.