With nearly 30,000 organ transplants being performed in the United States each year (Box 1),1 demand is growing for psychiatrists to provide presurgical and ongoing care.
How you might collaborate with a transplant team depends on each medical center’s protocols and individual patients’ mental health needs. A transplant candidate with depressive or anxiety symptoms may be referred to you for presurgical stabilization, for example, particularly if the patient lives far from a highly specialized transplant center.
Transplant assessments differ from usual psychiatric evaluations. Your findings will be used to help the transplant team evaluate the patient’s demographics, disease severity, and resources to give the patient the best chance for medical recovery. Inform patients at the beginning of the pretransplant evaluation that the results:
- will be shared with the transplant team
- may be used to help make decisions about transplant
- will not be the only factor determining if a transplant center will place a patient on an organ wait list.2
Pretransplant evaluation
Presurgical assessment helps determine the patient’s understanding of the transplant process and ability to provide consent (Table 1).3 Patients do not need a high level of medical sophistication to discuss transplantation, but they must understand the basics of the procedure and be able to rationally discuss their options. If a patient has severe cognitive impairment, dementia, or hepatic encephalopathy and cannot participate in the consent process, a surrogate is necessary.
Explore the patient’s attitudes and beliefs about transplant. If other team members have educated the patient about the procedure, your assessment can help determine how much the patient understood and if the patient has the capacity to make treatment decisions. Some patients believe the operation will “cure” them, despite education about the rigorous posttransplant routine. Alert the transplant team to these views, and begin aligning the patient’s views with reality.
Organ transplants: Not experimental anymore
In 2006, U.S. surgeons performed 28,931 organ transplants, bringing the total number of transplants since 1988 to >400,000. Each year, more kidney transplants are performed (17,091 in 2006) than all other organ transplants combined, according to the nonprofit United Network of Organ Sharing.1
Other organs being transplanted include liver, pancreas, heart, lung, and intestine. Some patients receive multiple organs, such as kidney/pancreas or heart/lung. As this article went to press, >96,000 candidates were on wait lists for organ donations.
Survival after transplantation has improved because of better immunosuppressant therapies introduced in the early 1980s and evolving physician and institutional experience. One-year survival rates for single-organ transplants range from 85% for lung to 98% for living donor kidney. Five-year survival rates range from 47% for lung to 86% for living donor kidney.
Source: Reference 1
Table 1
Psychiatric assessment of the pretransplant patient
| Assess understanding of his or her illness |
| Assess understanding of transplant process and ability to provide informed consent |
| Assess history of compliance with medical and psychiatric treatments |
| Identify substance abuse and other psychiatric comorbidities |
| Assess mental status |
| Evaluate social support system and possible interventions to bolster supports |
| Provide transplant team with information about patient’s need for education and support |
| Recommend treatment plan to address substance abuse and other psychiatric comorbidities |
| Source: Adapted from reference 3 |
Assessing psychiatric comorbidity. Like other patients with life-threatening medical illnesses, many transplant patients present with major depression and anxiety. Screen for symptoms of mood and anxiety disorders and past episodes of depression or mania. Explore the patient’s response to psychiatric treatment, current therapies, and history of treatment adherence.
Depression. Patients listed for transplant are seriously ill and coping with the difficulties of the sick role. Organ failure symptoms and resultant disability—such as insomnia, anorexia, fatigue, and impaired concentration—overlap with depression’s neurovegetative signs. Suspect depression if a patient presents with anhedonia, tearfulness, apathy, or guilt.
Among heart, lung, and liver transplant candidates, the reported lifetime prevalence of depression averages approximately 20%.4-6
Anxiety disorders. An estimated 40% of transplant patients have anxiety disorders,7 which may be caused by:
- stress of chronic illness
- uncertainty of the transplant process
- medical conditions such as hypothyroidism or pulmonary embolism.
Chronic mental illness. Patients with major mental illnesses such as schizophrenia might be appropriate candidates for organ transplant if they have adequate social support and history of treatment compliance.
Pharmacotherapy. Because of the variety of medical problems seen in transplant candidates, carefully consider medication side effects and drug-drug interactions when prescribing psychotropics.
Antidepressants. Among the selective serotonin reuptake inhibitors (SSRIs), citalopram, escitalopram, and sertraline are least likely to affect hepatic metabolism of other medications (Table 2).8 If a patient presents with liver failure, reduce the dosages of medications with hepatic metabolism.