Benzodiazepines. Use caution when treating anxiety with benzodiazepines because of the risk of tolerance, withdrawal, and dependence. Avoid benzodiazepines when treating transplant candidates with a substance abuse history. Also, these drugs might worsen hepatic encephalopathy and increase confusion.
Patients awaiting lung transplantation, especially those with high levels of CO2 retention, require special care because benzodiazepines might decrease respiratory drive. Try other agents such as buspirone, gabapentin, SSRIs, or second-generation antipsychotics to treat their anxiety.
Psychotherapy. Supportive psychotherapy can help patients navigate the often-lengthy process of waiting for a donor organ. Support groups for organ transplant candidates may help ease patients’ depressive symptoms.
Table 2
Antidepressants’ half-life and effect on hepatic metabolism
| Hepatic enzyme alterations | Half-life (hours) | |
|---|---|---|
| SSRIs | ||
| Fluoxetine | 2D6, 2C9, 2C19, 3A4 inhibition | 72 |
| Citalopram | None | 35 |
| Escitalopram | 2D6 inhibition (weak) | 32 |
| Sertraline | 2D6 inhibition (weak) | 30 |
| Paroxetine | 2D6 inhibition (strong) | 18 |
| Fluvoxamine | 1A2, 2C19, 2C9, 3A4 inhibition | 18 |
| Others | ||
| Mirtazapine | None | 30 |
| Bupropion SR | 2D6 inhibition | 21 |
| Venlafaxine XR | 2D6 inhibition | 5 |
| Trazodone | None | 5 |
| SSRIs: selective serotonin reuptake inhibitors | ||
| Source: Reference 8 | ||
Assessing substance abuse
Up to 50% of liver transplant candidates have a history of alcohol and/or drug abuse,9 the highest rate among transplant populations. Alcohol-induced cirrhosis and hepatitis C contracted from IV drug use are common indications for liver transplant. Effective treatment of substance abuse is essential because 30% to 50% of these patients relapse after the procedure.10 Assess:
- each substance abused, including onset, peak, and current use
- family history of substance abuse disorders
- past efforts at rehabilitation
- tobacco use (smoking before and after transplant is related to an increased incidence of new cancer diagnoses).11
Some transplant centers require patients with substance
use disorders to participate in 12-step programs or
rehabilitation. Regardless of the institutions’
requirements, encourage patients to participate in
rehabilitation to prevent relapse and mitigate the
negative impact of substance abuse on physical
and mental well-being.
Mental status examination includes the usual elements such as appearance, behavior, speech, affect, and thought process. Assess for suicidal thinking or hopelessness, which have been linked to serious medical illness.12 Question patients about hallucinations and give special attention to visual aberrations, which may occur in medically ill patients.
Cognitive testing. Use tools such as the Mini-Mental State Examination, clock drawing test, and Trail Making A and B tests to assess cognitive ability. If patients show signs of cognitive impairment, arrange for follow-up examinations and refer for neuropsychological testing.
Some cognitive impairment—such as that caused by hepatic encephalopathy—will likely improve after transplant, but other types—such as that caused by vascular disease—will not. If confusion is caused by hepatic encephalopathy, treatment with lactulose might rapidly improve symptoms. Remember that patients with hepatic encephalopathy might not exhibit elevated ammonia levels. Underlying causes of worsening hepatic encephalopathy—such as infections or bleeding—might require treatment.
Assessing adherence. Medication adherence after transplant is essential to prevent organ rejection and other complications. Posttransplant regimens are complex, and the frequency of follow-up assessments can be intense—particularly in the first year after transplant.
Your pretransplant assessment can identify where patients have struggled with adherence in the past. Before the transplant, your team can work to correct barriers such as inability to pay for medications, child care problems, or transportation needs.
Personality disorders have been identified as predictors of posttransplant nonadherence, and 50% to 60% of transplant programs consider personality disorders a relative contraindication to organ transplant.13 Address other contributors to poor adherence—such as substance abuse or depression—with ongoing psychiatric care.
What is ‘adequate’ social support?
When assessing a patient’s social support, look for evidence of:
- stable living situations
- long-term relationships with spouses, parents, children, or close friends
- adequate financial resources, including health insurance.
These factors help the patient manage the posttransplant process and numerous follow-up physician visits. Religious organizations or other social institutions also appear to provide the emotional support patients need to cope with an organ transplant.
Social support is essential to help with the normal difficulties such as frequent clinic visits and initial physical disability patients face after successful transplant (Box 2). Ask about the candidate’s family, friends, spirituality, and finances during your pretransplant assessment. Poor social support is related to the development of posttransplant psychiatric disorders14 and adherence difficulties.15
Assessment instruments—such as the Psychosocial Assessment of Candidates for Transplantation and the Transplant Evaluation Rating Scale3—include social support items and can be useful in identifying weak areas.
Data collected by other team members can be invaluable. A nurse or social worker, for example, may observe that a patient is unwilling to take medications, contrary to the patient’s report. Other sources of information include the patient’s family and friends, a primary care physician, or other mental health providers such as a therapist or case manager.