Med/Psych Update

Tools, techniques to assess organ transplant candidates

Current Psychiatry. 2007 September;6(9):56-66

References

1. United Network for Organ Sharing. Transplants by donor type. U.S. transplants performed: January 1, 1988 – April 30, 2007. Organ Procurement and Transplantation Network. Available at: http://www.unos.org. Accessed July 26, 2007.

2. Crone CC, Wise TN. Psychiatric aspects of transplantation, I: evaluation and selection of candidates. Crit Care Nurs 1999;19:79-87.

3. DiMartini AF, Dew MA, Trzepacz PT. Organ transplantation. In: Levenson JL, ed. The American Psychiatric Publishing textbook of psychosomatic medicine. Washington DC: American Psychiatric Publishing, Inc, 2005:675-700.

4. Cupples S, Dew MA, Grady KL, et al. Report of the psychosocial outcomes workgroup of the nursing and social sciences council of the international society for heart and lung transplantation: present status of research on psychosocial outcomes in cardiothoracic transplantation: review and recommendations for the field. J Heart Lung Transplant 2006;25:716-25.

5. Dew MA, DiMartini AF. Psychological disorders and distress after adult cardiothoracic transplantation. J Cardiovasc Nurs 2005;20:S51-S66.

6. Barbour KA, Blumenthal JA, Palmer SM. Psychosocial issues in the assessment and management of patients undergoing lung transplantation. Chest 2006;129:1367-74.

7. Trzepacz PT, Levenson JL, Tringali RA. Psychopharmacology and neuropsychiatric syndromes in organ transplantation. Gen Hosp Psychiatry 1991;13:233-45.

8. Crone CC, Gabriel GM. Treatment of anxiety and depression in transplant patients. Clin Pharmacokinet 2004;43:361-94.

9. DiMartini A, Weinrieb R, Mireman M. Liver transplantation in patients with alcohol and other substance use disorders. Psychiatr Clin North Am 2002;25:195-209.

10. Weinrieb RM, Van Horn DHA, McLellan AT, et al. Alcoholism treatment after liver transplantation: lessons learned from a clinical trial that failed. Psychosomatics 2001;42:110-6.

11. Jimenez C, Manrique A, Marques E, et al. Incidence and risk factors for the development of lung tumors after liver transplantation. Transpl Int 2007;20:57-63.

12. Juurlink DN, Herrmann N, Szalai JP, et al. Medical illness and the risk of suicide in the elderly. Arch Intern Med 2004;14:1179-84.

13. Levenson JL, Olbrisch ME. Psychosocial screening and selection of candidates for organ transplantation. In: Trzepacz PT, DiMartini AF, eds. The transplant patient. Cambridge, UK: Cambridge University Press, 2000:21-41.

14. Dew MA, Kormos RL, DiMartini AF, et al. Prevalence and risk of depression and anxiety-related disorders during the first three years after heart transplantation. Psychosomatics 2001;42:300-13.

15. Dew MA, Roth LH, Thompson ME, et al. Medical compliance and its predictors in the first year after cardiac transplantation. J Heart Lung Transplant 1996;15:631-45.

16. Dew MA, Myaskovsky L, Switzer GE, et al. Profiles and predictors of the course of psychological distress across four years after heart transplantation. Psychol Med 2005;35:1215-27.

17. Goetzmann L, Klaghofer R, Wagner-Huber R, et al. Psychosocial vulnerability predicts psychosocial outcome after an organ transplant: results of a prospective study with lung, liver, and bone-marrow patients. J Psychosom Res 2007;62:93-100.

18. Lucey M. Liver transplantation for alcoholic liver disease: a progress report. Graft 1999;2:S73-9.

19. Beresford TP. Neuropsychiatric complications of liver and other solid organ transplantation. Liver Transpl 2001;7(11 suppl 1):S36-S45.

Posttransplant psychiatric care

Depression. The incidence of depression is higher in the year following transplant than before transplant or in the immediate posttransplant period.⁵ Predictors of posttransplant depression include:

history of depression
poor social support
passive coping strategies
poor physical status after transplantation.^16,17

Carefully monitor patients who present with these factors after transplant. Treat depression with supportive measures designed to improve the patient’s social network and coping skills and pharmacotherapy. Select antidepressant medications based on side effect profiles and impact on the patient’s transplanted organs.

Substance abuse. Patients with a pretransplant history of substance abuse often relapse. Among transplant recipients with a history of alcoholic liver disease, drinking rates of 30% to 40% have been reported 5 years after transplant. Most of these data represent occasional use, not heavy or regular drinking.¹⁸ Relapse can occur despite careful assessment and follow-up.

Some evidence suggests that transplant patients who resume drinking have worse outcomes than those who abstain. Alcoholism relapse has other negative consequences, such as relationship problems and employment difficulties.

Predictors of relapse include:

pretransplant history of alcohol dependence
family history of alcoholism
rehabilitation history, which could indicate a severe substance abuse disorder.³

Medications for alcoholism treatment have not been studied systematically in transplant patients, but low doses of acamprosate, ≤2 g/d, and naltrexone, ≤200 mg/d, are options for patients interested in pharmacotherapy. Support from 12-step programs also helps treat substance-abusing patients.

Clinical Point

The incidence of depression is higher in the year following transplant than before transplant or immediately posttransplant

Altered mental status. Immunosuppressive medications—including cyclosporine, tacrolimus, and prednisone—can have neuropsychiatric effects and could cause a change in mental status (Table 3).¹⁹ Check cyclosporine and tacrolimus serum levels against reference ranges when delirium is present. If levels are toxic the dosage often can be lowered, which might lead to clinical improvement.

Quality of life. In general, patients’ quality of life improves after their transplant. After the first year—which patients might find difficult because of changes in physical and social status—quality of life typically improves.⁵

Table 3

Neuropsychiatric side effects of medications
commonly used in transplant patients

Medication	Side effects
Cyclosporine	Tremor, headache, seizures, hallucinations, delirium
Tacrolimus	Tremor, headache, vivid dreams, anxiety, anorexia, seizures, delirium
Prednisone	Depression, mania, psychosis, delirium
Source: Adapted from references 3,7

Psychiatric disorders such as depression can worsen quality of life. However, quality of life can improve after depression is diagnosed and treated. Other predictors of improved quality of life include older age, marriage, and the absence of a personality disorder.⁴

Other posttransplant concerns of patients include changes in employment, finances, and relationships. Patients often have been away from work before transplant, and returning after a long absence can be stressful. Patients may find that they cannot work as well as before becoming ill, which may lead to frustration, depression, and/or anxiety symptoms. Transplant surgery requires a large financial investment, and money concerns usually persist long after the transplant.

Clinical Point

Posttransplant patients might not be able to work as well as before becoming ill, leading to depression or anxiety

The transplant recipient’s role within the family may shift after surgery. Families might expect the patient to “return to normal” and resume old activities. Alternatively, family members might continue to treat the patient as a person with chronic illness despite physical improvement. If patients are struggling with these changes, supportive psychotherapy is indicated.

Related resource

United Network for Organ Sharing. www.unos.org.
Transplant living. www.transplantliving.org.
Trzepacz PT, DiMartini AF, eds. The transplant patient. Cambridge, UK: Cambridge University Press; 2000.
Klapheke MM. The role of the psychiatrist in organ transplantation. Bull Menninger Clin 1999;63(1):13-39.

Drug brand names

Acamprosate • Campral
Buspirone • BuSpar
Bupropion SR • Wellbutrin SR
Citalopram • Celexa
Cyclosporine • Sandimmune
Escitalopram • Lexapro
Fluoxetine • Prozac
Fluvoxamine • Luvox
Gabapentin • Neurontin
Lactulose • Cephulac, Chronulac
Mirtazapine • Remeron
Naltrexone • ReVia
Paroxetine • Paxil
Prednisone • Deltasone
Sertraline • Zoloft
Tacrolimus • Prograf
Trazodone • Desyrel

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.