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W4213384897 abstract "Back to table of contents Previous article Next article INFLUENTIAL PUBLICATIONFull AccessOrgan TransplantationAndrea F. DiMartini, M.D., Mary Amanda Dew, Ph.D., and Paula T. Trzepacz, M.D.Andrea F. DiMartiniSearch for more papers by this author, M.D., Mary Amanda DewSearch for more papers by this author, Ph.D., and Paula T. TrzepaczSearch for more papers by this author, M.D.Published Online:1 Apr 2005https://doi.org/10.1176/foc.3.2.280AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The benefit of solid organ transplantation was realized in 1954 when Dr. Joseph E. Murray performed the first successful kidney transplant, with the patient’s identical twin as donor. However, for most patients an identical-twin donor was not an option, and more than a decade passed before immunosuppressive medications were available to conquer the immunological barrier. In 1967, the first successful liver transplant was performed, followed a year later by the first successful heart transplant. Yet despite the fact that the surgical challenges of solid organ transplantation had been overcome, it was not until the early 1980s, with the advent of improved immunosuppression, that organ transplantation changed from an experimental procedure to a standard of care for many types of end-stage organ disease.In that decade, the National Organ Transplant Act established the framework for a national system of organ transplantation, and the United Network of Organ Sharing (UNOS) was contracted by the U.S. Congress to administer the nation’s only Organ Procurement and Transplantation Network (OPTN) (United Network of Organ Sharing 2004). Currently, UNOS administers the OPTN under contract with the U.S. Department of Health and Human Services. In addition to facilitating organ matching and placement, UNOS collects data about every transplant performed in the United States and maintains information on every organ type (e.g., wait-list counts, survival rates) in an extensive database available on the OPTN Web site (http://www.OPTN.org) (United Network of Organ Sharing 2004).Although immunological barriers still exist for transplant recipients, the greatest obstacle to receiving a transplant is the shortage of donated organs. The number of wait-listed individuals is increasing far beyond the availability of donated organs. As illustrated in Figure 1, the numbers of wait-listed patients for kidney (the most frequent) and liver transplants increased steadily between 1995 and 2001 (United Network of Organ Sharing 2004). By contrast, the numbers of patients waiting for heart, lung, and pancreas transplants increased only marginally during the same period. The median wait-listed time depends on the organ type, the blood type of the recipient, and the severity of the recipient’s illness at the time of listing. For example, as of 2001, the median wait time for a heart transplant candidate initially listed as a category heart status 2 was 374 days, whereas that for a liver transplant candidate listed as a UNOS 2B was 282 days (United Network of Organ Sharing 2004). Figure 2 shows the numbers of transplant recipients in 2001 for each solid organ type (United Network of Organ Sharing 2004), which ranged from a low of 924 for lung to a high of 11,502 for kidney. These numbers are much lower than the 2001 wait-listed values, and ratios of transplant recipients to wait-listed patients are lowest for kidney, liver, and lung (about 1:4 to 1:5). Each year, 10%–15% of liver, heart, and lung transplant candidates will die while on the waiting list (United Network of Organ Sharing 2004). Additionally, posttransplantation graft survival rates can be significantly lower (e.g., 36.4% kidney and 45% liver graft survival after 10 years) than patient survival rates, which means that many transplant recipients will have to face a second transplant 5–10 years after their first (Figure 3) (United Network of Organ Sharing 2004).These stark facts highlight the enormous stresses facing transplant candidates, transplant recipients, and their caregivers. These issues have also created a particular environment in which hospitals must evaluate, treat, and select patients for organ transplantation. The scarcity of donated organs has driven efforts to select candidates believed to have the best chance for optimal posttransplant outcomes. Additionally, the organ shortage has increasingly led to the consideration of living kidney donors and, more recently, living liver donors (and, more rarely, living lung donors) as transplantation options.Pretransplant psychosocial evaluations are commonly requested to assist in candidate and donor selection, and psychiatric consultation is often needed for clinical input during the pre- and posttransplant phases. Although a wide body of knowledge has been developed in the clinical care of transplant candidates and recipients, little longitudinal research is available to answer questions about long-term outcomes or the impact of psychiatric factors (assessed pretransplant and/or in the early years posttransplantation) on outcomes. Research primarily has focused on kidney, heart, and liver transplantation, which in combination currently account for almost 90% of transplants performed in the United States.In this chapter, we outline the essential areas of the field for psychosomatic medicine specialists and other mental health clinicians involved in the care of transplant patients—pretransplant assessment and candidate selection, emotional and psychological aspects of the transplant process, therapeutic issues, patients with complex or controversial features, psychopharmacological treatment, and neuropsychiatric side effects of immunosuppressive medications. Special pretransplantation topics of emerging importance to psychosomatic medicine specialists are also discussed (i.e., hepatic encephalopathy, ventricular assist devices in heart transplantation, tobacco use, and living donors). The neuropsychiatric sequelae of end-stage organ disease are not covered in this chapter, because those aspects are addressed in the respective chapters on each organ system. Specific transplant issues are also discussed in Chapter 19, “Heart Disease”; Chapter 20, “Lung Disease”; Chapter 22, “Renal Disease”; and Chapter 34, “Pediatrics.”Pretransplantation issuesPsychosocial/psychiatric assessmentPretransplant psychosocial evaluations have been a traditional role of the psychiatric consultation team in the transplantation process. These evaluations are frequently used to assist in the determination of a candidate’s eligibility for transplantation, to identify psychiatric/psychosocial problems that may need to be addressed to prepare the candidate and family for transplantation, and to identify pre- and posttransplant psychiatric and/or psychosocial needs of the candidate. These evaluations are also critical for the identification of psychiatric, behavioral, and psychosocial risk factors that may portend poor transplant outcomes (Crone and Wise 1999; Dew et al. 2000b).Transplant programs will often refer for evaluation candidates with a known history of psychiatric problems or those who are identified during the initial clinical interviews with the transplant team as having such problems. Pretransplant psychosocial evaluations are also usually requested for patients with substance use disorders (including tobacco) and other poor health behaviors (e.g., obesity, noncompliance).Although a truly comprehensive assessment of a potential transplant candidate would require a full psychiatric consultation, the current high numbers of candidates preclude this. To handle the increasing volume of evaluations, some centers employ screening batteries of patient-rated measures to identify candidates with elevated levels of psychological distress, who then undergo a full psychiatric evaluation. Screening instruments can provide baseline cognitive, affective, and psychosocial ratings for candidates; use of these instruments maximizes staff resources and minimizes costs. For example, using this strategy, Jowsy et al. (2002) identified 20%–44% of liver transplant candidates who had mild to severe symptoms on a range of measures, which prompted a higher level of evaluation.Emerging evidence shows that preoperatively assessed psychosocial variables can predict posttransplantation psychiatric adjustment among recipients of most organ types (Dew et al. 2000b). These variables are increasingly being investigated as contributing to medical outcomes as well, although a consistent predictive effect has not yet been demonstrated (Dew et al. 2000b). Thus, psychosocial assessment of transplant candidates provides an opportunity to identify potential problems and intervene prior to transplantation, with the goal of improving posttransplant outcomes. Transplant programs vary considerably in their psychosocial assessment criteria and procedures (see Olbrisch and Levenson 1995 for a review of methodological and philosophical issues); in general, however, psychosocial evaluations have 10 objectives (although a given assessment may not include all 10), as enumerated in Table 1 (see Levenson and Olbrisch 2000).Because information on all of these domains may not be obtainable during a single clinical interview, a follow-up reassessment may be necessary to clarify relevant issues, solidify a working relationship with the patient and family, and resolve problems. A multidisciplinary approach is often used with input from psychiatrists, psychologists, psychiatric nurse clinical specialists, addiction specialists, social workers, transplant surgeons, and transplant coordinators to construct a comprehensive picture of the patient and develop a coordinated treatment plan. As with any psychiatric evaluation, verbal feedback provided to the patient and family will serve to solidify the expectations of the transplant team and the requirements of the patient for listing if indicated. Some centers also use written “contracts” to formalize these recommendations (Cupples and Steslowe 2001; Stowe and Kotz 2001). In difficult cases, these contracts serve to document expectations, thereby minimizing misinterpretation. Written contracts outline a treatment plan that can be referred to with each follow-up appointment. These contracts are particularly useful with transplant candidates who have alcohol or substance abuse/dependence problems, specifying the transplant program’s requirements for addiction treatment, monitoring of compliance (e.g., documented random negative blood alcohol levels), and length of abstinence (see subsection “Alcohol and Other Substance Use Disorders” later in this chapter).Psychosocial instruments and measuresTransplant-specific (e.g., Psychosocial Assessment of Candidates for Transplant [Olbrisch et al. 1989], Transplant Evaluation Rating Scale [Twillman et al. 1993]), disease-specific (e.g., Miller Health Attitude Scale for cardiac disease [Miller et al. 1981], Quality of Life Questionnaire—Chronic Lung Disease [Guyatt et al. 1987]), and disorder-specific (e.g., High Risk Alcohol Relapse Scale for alcoholism [Yates et al. 1993]) instruments have been used to evaluate transplant candidates and monitor their posttransplant recovery. These instruments have been used in conjunction with general instruments for rating behavior, coping, cognitive and affective states, and quality of life. Psychosocial instruments can be used to identify individuals who require further assessment (as described earlier) or to pursue evaluation of patients already identified as requiring additional screening. The evaluator’s purpose for using such instruments will determine the type and specificity of the instruments chosen; for instance, in the subsection “Hepatic Encephalopathy” later in this chapter, we discuss the use of neuropsychiatric tests to aid in the identification of cognitive impairment. Some instruments are more applicable to transplant populations than others. For example, although there are many instruments and measures for assessing alcoholism, none of these instruments are tailored to transplant candidates; they are focused on general issues of detection and treatment of addiction rather than on issues important in evaluating appropriateness for transplantation.Because psychosocial selection criteria differ significantly by program and organ type, development and use of structured evaluation instruments may help to direct and standardize the transplant selection protocols used nationally. The two instruments most commonly used to assess candidates for transplantation are the Psychosocial Assessment of Candidates for Transplantation and the Transplant Evaluation Rating Scale.The Psychosocial Assessment of Candidates for Transplantation (PACT) was the first published psychosocial structured instrument specifically designed for screening transplant candidates (Olbrisch et al. 1989). It provides an overall score and subscale scores for psychological health (psychopathology, risk for psychopathology, stable personality factors), lifestyle factors (healthy lifestyle, ability to sustain change in lifestyle, compliance, drug and alcohol use), social support (support system stability and availability), and patient educability and understanding of the transplant process. The PACT can be completed in only a few minutes by the consultant following the evaluation but requires scoring by a skilled clinician, without which the instrument’s predictive power could be diminished (Presberg et al. 1995). The final rating for candidate acceptability is made by the clinician, with the freedom to weigh individual item ratings variably (Presberg et al. 1995). Thus, a single area, such as alcohol abuse, could be assigned greater weight and thus could disproportionately influence the final rating.The PACT has been used to predict mortality in bone marrow recipients (independent of age, gender, or diagnosis), as well as to predict hospital lengths of stay following liver transplantation (Levenson et al. 1994). Its “risk for psychopathology” subscale identifies psychopathology that may require referral and treatment after liver, heart, and bone marrow transplantation (Levenson et al. 1994).The Transplant Evaluation Rating Scale (TERS) is used to rate patients’ level of adjustment in 10 areas of psychosocial functioning: prior psychiatric history, DSM-III-R Axis I and Axis II diagnoses, substance use/abuse, compliance, health behaviors, quality of family support, prior history of coping, coping with disease and treatment, quality of affect, and mental status (Twillman et al. 1993). In one study, the TERS was significantly correlated with several clinician-reported outcome variables (compliance, health behaviors, substance use), with particularly high correlations between pretransplant TERS scores and posttransplant substance use (r=0.64) (Twillman et al. 1993). The instrument requires administration by a skilled clinician to maintain accuracy (Presberg et al. 1995). The TERS summary score is derived from a mathematical formula in which individual item scores are multiplied by theoretical, predetermined weightings.Although individual candidates do not always easily fit within one of the three categories of each item on the TERS, the TERS has more items than the PACT, a feature that may prove useful in future research (Presberg et al. 1995). However, the PACT is the more flexible of the two instruments, both in the range of rating individual items and in the manner in which the summary score is determined (Presberg et al. 1995). Together, these instruments are useful in the organization of patient information and can be helpful both as tools for increasing the evaluator’s understanding of the candidate and for research purposes.The unique role of the psychiatric consultantUnlike in most psychiatric interviews, the psychiatrist performing the pretransplant assessment primarily serves the needs of the transplant team rather than those of the patient (a possible exception is the evaluation of living organ donors; see subsection “Living Donor Transplantation” later in this chapter). The psychiatric consultant must be candid with the patient about this role. Careful delineation of specific transplant-related expectations, explanation of the importance of these requirements to the success of transplantation, and exploration of the implications of these criteria for the individual candidate serve to establish a meaningful dialogue with the patient from which the therapeutic alliance necessary for future intervention can develop.For the clinician, the seemingly reverse nature of this role can be uncomfortable or even anxiety provoking. This is especially true if the clinician is not recommending the candidate for transplantation. Fortunately, many programs do not reject patients outright for psychosocial reasons; rather, they offer such patients the opportunity to work to bring their problematic areas into compliance with the recommendations (i.e., through addiction counseling, behavioral changes, psychiatric treatment, identification of appropriate social supports) and then undergo reevaluation for candidacy. In these cases, the psychiatric consultant can often function as an advocate for the patient and assist in referral for appropriate treatment if indicated. Nevertheless, some patients will be unable to comply with the specified transplant requirements or will not survive to complete their efforts to meet candidacy requirements.Philosophical, moral, ethical, legal, and therapeutic dilemmas are inherent in the role of transplant psychiatrist, as conflicting team opinions present themselves in the course of work with potential transplant candidates. Team discussions and consultation with other colleagues are the rule in complicated cases. In these instances, team discussions not only aid in resolving candidacy quandaries but also can help alleviate team members’ anxiety and discomfort over declining a patient for transplantation. Group or team debriefing may also be desirable, and occasionally consultation with risk management and the legal department of the hospital is needed (e.g., when a candidate is challenging candidacy requirements or the candidacy decision of the transplant team). Thorough documentation is essential in order to delineate the issues involved, the expectations of the team for transplantation candidacy, and the efforts to work with the patient.Psychological and psychiatric issues in organ transplantationPsychiatric symptoms and disorders in transplant patientsSimilar to other medically ill populations, transplant candidates and recipients experience a significant amount of psychological distress and are at heightened risk of developing psychiatric disorders. The prevalence rates of major depression range from 4% to 28% in liver transplant patients, 0% to 58% in heart transplant patients, and 0.4% to 20% in kidney transplant patients (Dew 2003; Dew et al. 2000b). The range of rates for anxiety disorders appears to be 3% to 33% (Dew 2003; Dew et al. 2000b), but there are not enough studies to identify specific types of anxiety disorders. One study found that 10% of a cohort of heart or lung transplant recipients experienced posttraumatic stress disorder (PTSD) related to their transplant experience (Köllner et al. 2002). In a prospective study of 191 heart transplant recipients, the cumulative prevalence rates for psychiatric disorders during the 3 years posttransplantation were 38% for any disorder, including 25% with major depression, 21% with adjustment disorders, and 17% with PTSD (Dew et al. 2001a). Factors that increased the cumulative risk for psychiatric disorders included a pretransplant psychiatric history, a longer period of hospitalization, female gender, greater impairments in physical functioning, and fewer social supports (Dew et al. 2001a).Several studies have suggested an association between psychiatric disorders and transplant health outcomes, although the results have been mixed. A study of wait-listed liver transplant candidates found that candidates with Beck Depression Inventory (BDI) scores higher than 10 (64% of patients) were significantly more likely than nondepressed candidates to die while awaiting transplantation (Singh et al. 1997). The higher BDI scores were due more to psychological distress than to somatic symptoms. However, for candidates who reached transplantation, pretransplant depression was not associated with poorer posttransplant survival (Singh et al. 1997). These results were not affected by the severity of and complications from liver disease, or by patients’ social support, employment, or education (Singh et al. 1997). A study of lung transplant recipients found that those with a pretransplant psychiatric history (anxiety and/or depressive disorders) were more likely than those without such a history to be alive 1 year after transplantation (Woodman et al. 1999). However, in a study of 191 heart transplant recipients, a DSM-III-R diagnosis of PTSD (with the traumatic event being transplant related) was associated with higher mortality (odds ratio=13.74) (Dew and Kormos 1999). Another study of heart transplant recipients found that patients with ischemic cardiomyopathy and high self-rated depression scores pretransplant had significantly higher posttransplant mortality compared with the low-depression group after adjustment for sociodemographic and somatic symptoms (Zipfel et al. 2002). Although causal directions cannot be inferred from these data, studies in other medically ill populations have demonstrated the substantial contribution of depression and anxiety to health outcomes (see Chapter 9, “Depression,” and Chapter 12, “Anxiety Disorders”). Whether treating these disorders will affect patient outcomes is unclear. However, the role of the psychiatrist in evaluating, diagnosing, and treating psychiatric disorders both pre- and posttransplantation is critical.Adaptation to transplantationTransplant candidates typically experience a series of adaptive challenges as they proceed through evaluation, waiting, perioperative management, postoperative recuperation, and long-term adaptation to life with a transplant (Olbrisch et al. 2002). With chronic illness, there can be progressive debility and gradual loss of vitality and of physical and social functioning. Adapting to these changes can elicit anxiety, depression, avoidance, and denial and requires working through of grief (Olbrisch et al. 2002). Patients who are wait-listed may develop contraindications to transplantation (i.e., infection, serious stroke, progressive organ dysfunction), and both patients and families should be made aware that a candidate’s eligibility can change over time for many reasons (Stevenson 2002). During this phase, psychiatrists may provide counseling to patients and families to help them prepare for either transplantation or death.The summons for transplantation can evoke a mixture of elation and great fear. Many programs use electronic pagers to contact recipients, and some patients can develop anxiety related to anticipation of the pager’s ring. Patients may experience a panic attack when they are called for transplantation, and some may even decline the offer of an organ.Much of illness behavior depends on the coping strategies and personality style of the individual. In our experience, the adaptive styles of adult transplant recipients often depend on whether patients’ pretransplant illness experience was chronic or acute, as delineated in the following broadly generalized profiles.Patients who have dealt with chronic illness for years may adapt psychologically to the sick role and can develop coping strategies that perpetuate a dependency on being ill (Olbrisch et al. 2002). For these patients, transplantation may psychologically represent a transition from one state of illness to another, and such patients can have difficulty adjusting to or transitioning into a “state of health.” They often complain that the transplant team is expecting too fast a recovery from them, and they may describe feeling pressured to get better. Some patients may develop unexplained chronic pain or other somatic complaints or may begin to evidence noncompliance with transplant team directives.For patients with good premorbid functioning who become acutely ill, with only a short period of pretransplant infirmity, the transplant can be an unwelcome event. These patients can experience a heightened sense of vulnerability, and they may deny the seriousness of their medical situation (Olbrisch et al. 2002). These patients often wish to return to normal functioning as quickly as possible posttransplantation, and they may in fact recover more rapidly than the transplant team expects; however, they may suffer later as the result of pushing themselves too much (e.g., returning to work before they are physically ready). They may resent being a transplant recipient, with all of the restrictions and regimens inherent in that role, and may act out their anger or denial in episodes of noncompliance (Olbrisch et al. 2002).Treatment modalitiesA prospective study of kidney transplant recipients demonstrated that individual psychotherapy was effective in resolving transplant-related emotional problems, with significant reductions in BDI scores after therapy (Baines et al. 2002). Three recurring psychological themes were expressed by patients in this study: 1) fear of organ rejection, 2) feelings of paradoxical loss after surgery despite successful transplantation, and 3) psychological adaptation to the new kidney (Baines et al. 2002).In addition to traditional therapies and pharmacotherapy (see section “Psychopharmacological Treatment in End-Stage Organ Disease” later in this chapter), various innovative strategies have been employed to deal with specific issues of transplantation and also to address logistical and staffing resource issues. At the University of Toronto, a mentoring program was developed for heart transplant recipients. Mentorship by an already transplanted recipient augmented patient care by providing information and support from a peer perspective (Wright et al. 2001). The four topics most commonly discussed between mentors and mentees were postoperative complications (70%), medications (70%), wait on the transplant list (70%), and the surgery itself (50%) (Wright et al. 2001). Participants less frequently discussed psychiatric topics such as anxiety (40%) and depression (10%) and personal topics such as sexual relations (20%) and marital problems (10%). The program was well received, and patients were very satisfied with the experience. To increase patient satisfaction with the mentor program, Wright and colleagues recommend early introduction of a mentor and matching of mentors with mentees according to demographics and clinical course (Wright et al. 2001).Group therapy for organ transplantation patients and family members has also been successfully used. At the Toronto Hospital Multi-Organ Transplantation Program, group psychotherapy is organized along three dimensions: course of illness (pre- vs. posttransplantation), homogeneous versus heterogeneous group membership (e.g., separate groups for patients and caregivers vs. integrated groups, organ-specific groups vs. cross-organ groups), and group focus (issue-specific vs. unstructured) (Abbey and Farrow 1998). Increasing levels of group therapy intensity are used, depending on the needs of the patient. Educational groups are mandatory for pretransplant candidates to prepare them for transplantation. From these groups, candidates at risk for psychosocial problems are referred to supportive and psychoeducational groups. Interpersonal and supportive–expressive psychotherapy groups are available to those who require them and have the psychological capacity to benefit from them. Group therapy participants report decreases in negative affect, increases in positive affect and happiness, less illness intrusiveness, and improved quality of life (Abbey and Farrow 1998). Transplant coordinators also report that patients in group therapy require less contact, both in clinic and by telephone for social support (Abbey and Farrow 1998).Dew and colleagues (2004) have developed an innovative strategy for managing the logistical problem of recipients living at a distance from the transplant program. These researchers designed and evaluated an Internet-based psychosocial intervention for heart transplant recipients and their families. This multifaceted Web-based intervention included stress and medical regimen management workshops, monitored discussion groups, access to electronic communication with the transplant team, and information on transplant-related health issues (Dew et al. 2004). Compared with heart recipients without access to the Web site, intervention patients reported significant reductions in depressive and anxiety symptoms and improved quality of life in the social functioning domain; in addition, caregivers of intervention patients reported significant declines in anxiety and hostility symptoms (P<0.05). Mental health and quality-of-life benefits were greater among more-frequent users of the Web site. The subgroup using the Web site’s medical regimen workshop showed significantly better compliance at follow-up than did all other patients in attending clinic appointments, completing blood work, and following diet (Dew et al. 2004). Dew and colleagues concluded that a Web-based intervention could improve follow-up care, compliance, and mental health in patients and families as they adjust to heart transplantation.Patients with complex or controversial psychosocial and psychiatric issuesThe stringency of selection criteria for transplantation appears to depend on the type of organ transplant being consid" @default.
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