transplant psychiatry curley l. bonds, md associate professor & chair department of psychiatry...
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Transplant PsychiatryTransplant Psychiatry
Curley L. Bonds, MDCurley L. Bonds, MDAssociate Professor & ChairAssociate Professor & Chair
Department of Psychiatry & Human Department of Psychiatry & Human BehaviorBehavior
Charles Drew University School of Charles Drew University School of MedicineMedicine
Associate Clinical Professor & Vice-ChairAssociate Clinical Professor & Vice-ChairDepartment of PsychiatryDepartment of Psychiatry
David Geffen School of Medicine at UCLADavid Geffen School of Medicine at UCLA
Overview
• Brief overview of solid organ transplantation• Rationale for psychosocial screening• Role of psychosocial screening• Predictive value of psychosocial assessment • Pre-operative and post-operative issues• Pharmacological aspects of cardiac
transplantation• Challenges for the Organ Transplant
Psychiatrist
Scope of Solid Organ Transplantation
• Kidney• Kidney/Pancreas• Liver• Heart • Lung• Small Bowel• Special Senses (Cornea, Cochlea,
etc.)• Limbs (Face, Hand)
History of Organ Transplantation
• First successful transplant: 1951 (kidney)
• First partial success: 1953 (kidney, patient survived 175 days)
• First twin-to-twin transplant: 1954 (patient survived until 1962)
Waiting List as of 1/21/07
94,759 Waiting list candidates
24,438 Transplants (January - October 2006)
12,395 Donors(January - October 2006)
UNOS website data
The Transplant Team
• Transplant Surgeon• Internists & Sub-specialists• Psychiatrist/Psychologist• Transplant Coordinators/Nurses• Social Worker• Ethicists/Pastoral Services• Community Members
Pre-Transplant Evaluation
• Psychosocial Assessment– Past Psychiatric History– Current psychiatric symptoms/illness– Psychotropic use– Substance use history– Social support– Cognitive evaluation– Understanding & Knowledge
Determining Transplant Candidacy
PsychPsych
So
cial
So
cial
BioBio
AssessmentAssessment
Biopsychosocial Screening
Suitability for Transplant
ComplianceSocial Supports
Understanding &Knowledge
Recipient’s History and Habits
The Transplant Patient
Biological, psychiatric and ethical issues in organ transplantation
Ed. By Paula Trzepacz & Andrea DiMartini
© Cambridge University Press 200
Rationale for Psychosocial Screening
• Learn whether the patient will be able to form collaborative relationships with team and comply with medical regimen
• Assess substance abuse history and recovery, and predict patient’s ability to maintain abstinence
• Help the team get to know the patient as a person to provide better care
Rationale for Psychosocial Screening
• To learn about the psychosocial needs of the patient and family, and plan for services during the waiting, recovery, and rehab phases of the transplant process
• To establish baseline measures of mental functioning to monitor post-op changes
Rationale for Psychosocial Screening
• Predict the recipient's ability to cope with the stresses of surgery
• Identify co-morbid mental illnesses and plan interventions for them
• Ensure adequate education and understanding/informed consent
Psychological evolution and assessment in patients
undergoing OHT
Triffaux, Wauthy, Bertrand et al.European Psychiatry 2001: 16: 180-5
Pre OHT Screening
• Twenty-two consecutive transplant candidates underwent psychiatric evaluation
• Patients completed multiple questionnaires during the waiting period, then at 1 and 6 months after OHT
Measures Employed
• Speilberger’s State-Trait Anxiety Inventory
• Beck Depression Inventory• Perceived Social Support Scale• Toronto Alexithymia Scale• Personal Reaction Inventory
Pre-operative pathology
• 41% (n=9) of patients had some DSM IV Axis I Diagnosis
• 18% (n=4) presented with an Axis II condition
Psychosocial Risk Factors for Noncompliance
• History of substance abuse• Age <30• Experiencing economic or psychosocial
stress
Surman 1992
Psychosocial Factors Associated with Poor Transplant Outcomes
• Poor social support• Psychiatric disorders likely to
compromise adequate postoperative compliance (affective disorders, psychosis, anxiety disorders, etc.)
• Self-destructive behaviors including nicotine, alcohol and drug abuse
Psychosocial Factors Associated with Poor Transplant Outcomes
• Poor compliance with medical treatment (combined with a continued failure to appreciate the necessity of change)
• Intractable maladaptive personality traits (such as oppositionality or counter-dependence)
Prognostic Factors for Substance Dependence and Abuse Recidivism
POSITIVE FACTORS• Stable living environment• Resources for abstinence• Recognition and
acceptance of dependence as a problem
• Absence of concurrent psychiatric disorders
• Compliance with post-transplant recommendations for addictions care
NEGATIVE FACTORS• Preexisting psychotic
disorder• Unstable character
disorder• Unremitting polydrug
abuse• Multiple failed attempts
at rehab• Social isolation
Evaluation Process
• >95% of US programs utilize some form of pre-transplant psychosocial evaluation process
• ~25% of US programs require formal psychological testing as part of the screening process
• In 1990, pre-operative screening rates were highest among OHT programs (23%) compared to liver and kidney program
Levinson & Olbrisch, 2000
Psychotic Disorders as a Contraindication to OHT at US Transplant Programs
AbsoluteContraindication
Relative Contraindication
Irrelevant
ActiveSchizophrenia
92.3% 5.1% 2.6%
ControlledSchizophrenia
33.3% 51.3% 15.4%
Levinson & Olbrisch, 2000
Affective Disorders as a Contraindication to OHT at US Transplant Centers
Absolute Contraindication
Relative Contraindication
Irrelevant
Current Affective Disorder
44.9% 47.4% 7.7%
Hx of Affective Disorder
5.1% 62.8% 32.1%
Levinson & Olbrisch, 2000
Suicidal Ideation/Attempts as a Contraindication to OHT at US Transplant Centers Absolute
Contraindication
Relative Contraindication
Irrelevant
Recent Suicide Attempt
51.3% 41.0% 7.7%
Distant Suicide Attempt
12.8% 64.1% 23.1%
Hx of Mult. Suicide Attempts
71.8% 24.4% 3.8%
Current SI 75.6% 17.9% 6.4%
Mental Retardation/IQ as a Contraindication to OHT at US Transplant Centers
Absolute Contraindication
RelativeContraindication
Irrelevant
MRIQ >70 25.6% 59.0% 15.4%
MRIQ <70 74.4% 19.2% 6.4%
Levinson & Olbrisch, 2000
Dementia as a Contraindication to OHT at US Transplant Centers
• Absolute contraindication: 71.8%• Relative contraindication: 23.1%• Irrelevant: 5.1%
Levinson & Olbrisch, 2000
Character Disorder as a Contraindication to OHT at US Transplant Centers
• Absolute contraindication: 14.1%• Relative contraindication: 62.8%• Irrelevant: 5.1%
Levinson & Olbrisch, 2000
Assessment Tools
• TERS - Transplant Evaluation Rating Scale
• PACT – Psychosocial Assessment of Candidates for Transplantation
Predictive Value of Pre-Op Assessment
Psychiatric Disorders and Outcome Following Cardiac Transplantation
Skotzko, et al., J. of Heart and Lung Transplantation, 1999
Predictive Value of Pre-Op Assessment
• 107 OHT recipients• Transplanted Jan. ’90 - Sept. ’91• Retrospective chart review• Medical outcomes measured:
1 year survivalrehospitalizationsinfectionsrejections
Predictive Value of Pre-Op Assessment
• Group I (n=25) Any Axis I Dx• Group II (n=82) No Axis I Dx
• Findings: No significant difference between Groups I and II at 1 year
• Implications
GuiltGuilt
Anx
iety
Anx
iety
Depression
Depression
Dis
abili
ty
Dis
abili
ty
WaitingWaiting
Pre-Operative Issues
UNOS Heart Allocation Policy
• Status 1A Pt requires: Continuous hemodynamic monitoring and cardiac or pulmonary assistance with one or more of the following:
- cont. IV or inotropes- left and/or right ventricular assist system- intraaortic balloon pump or ventilator for
pts<45- all pts < 6 months old
• Status 1BPt requires: a circulatory assist device or admission to an acute care hospital and continuous infusion of IV inotropes
UNOS Heart Allocation Policy
• Status 2APatient requires continuous infusion of IV inotropes
• Status 2BPatients needing a heart transplant but not meeting criteria for 1A, 1B or 2A
Pre-Operative Interventions
• Transplant Support Group• Internet/Online Support Groups• National Heart Association• Transplant Olympics• Individual Psychotherapy• Antidepressants/Anxiolytics
Body Image
Body Image
New
Med
s
New
Med
s
Role Strain
Role Strain
Fina
ncia
l
Fina
ncia
l
RehabilitationRehabilitation
Post-Operative Issues
1st Three Years after OHT
• 191 OHT recipients were followed for 3 years:– Major Depressive Disorder
25.5%– Adjustment Disorders
20.8%– PTSD-T 17%– Any Disorder 38%
Dew, Kormos, et al Psychosomatics2000
Psychological Changes in the Recipient
• Castelnuovo-Tedesco– Expansion of body image– Incorporation of a non-ego ‘part object’ – Ambivalence towards a live-giving
object that can also be lethal
“This is the matrix in which one finds besides depression, blissful euphoria or paranoid dread.”
Ageism and Transplantation
• Most US Transplant Programs use age 65 as an automatic cut off for transplantation
• Medical data now shows that transcipients over 65 can do as well as younger patients
• Led to the Alternate Transplant List at UCLA
UCLA Experience
Subjects with Axis I Disorders vs Subjects with No Psychiatric Disorders*
3
24
19 19 19
2
24
29
44
20
0
5
10
15
20
25
30
35
40
45
50
Mortality 1 Year Rejection 1 Year Infection 2 Year Infection Readmissions
Pe
rce
nta
ge
Subjects with Axis I Disorders(N=21)
Subjects with No PsychiatricDisorders (N=31)
*p values insignificant
UCLA Alternate Transplant List
Subjects >65, Axis I Disorders vs No Psychiatric Disorders*
0
33
67 67
33
0
67
83 83
50
0
10
20
30
40
50
60
70
80
90
Mortality 1 Year Rejection 1 Year Infection 2 Year Infection Readmissions
Pe
rce
nta
ge
Subjects >65 with Axis I Disorders(N=3)Subjects >65 with No PsychiatricDisorders (N=6)
*p values insignificant
UCLA Experience: Axis II Pathology
Subjects with Axis II Disorders vs Subjects with No Psychiatric Disorders*
0
67
33
67
0
3
24
29
44
20
0
10
20
30
40
50
60
70
80
Mortality 1 Year Rejection 1 Year Infection 2 Year Infection Readmissions
Pe
rce
nta
ge
Subjects with Axis II Disorders(N=3)
Subjects with No PsychiatricDisorders (N=24)
*p values insignificant
Psychiatric Evaluations of Heart Transplant Candidates: Predicting Post-Transplant Hospitalizations, Rejection Episodes, and Survival
Owen, Bonds, WellischPsychosomatics 2006: 47:213-222
Predicting Outcomes
• There is no consensus among clinicians about which candidates are acceptable or unacceptable
• While psychosocial risk factors are routinely used to determine candidacy, there is limited predictive validity of the methods used
Hypothesis
• Previously identified psychiatric risk factors (eg. Recent substance abuse, history of suicide attempt, having a personality disorder, low levels of social support, and poor past adherence to medical regimens) would be associated with a greater likelihood of post-transplant complications
Outcome Measures
• Re-hospitalization/Rejection• Infection• Death
Methods
• 108 OHT recipients followed for average of 970 days
• Transplanted between 1997 and 2000
• >18 years old• Followed by UCLA Heart Transplant
Team
Findings –Psychiatric Risk Factors
• 77.8 had evidence of current Axis I disorder at time of evaluation– 40.4% mood disorder– 30.8% depression-related dx– 14.4% anxiety-related dx– 6.7% sleep disorder– 27.8% ETOH dependence or abuse
• 5.6% actively dependent on ETOH
• 41.7% using psychotropic meds
Risk Assessment
• Good Candidates – 50%• High Risk- 11.1%
Predictors of Transplant Outcomes
• Increasing psychiatric risk classification was associated with a greater hazard of post-transplant mortality, but was not predictive of either post-transplant infection (p=0.10) or hospitalization (p=0.62)
• Past history of suicide attempt strongly associated with time to infection/rejection
Predictors of Death
• 5 variables were associated with survival– Current employment (increases)– Hx of drug or ETOH detox– Current depressive disorder– Hx of past suicide attempt– Hx of poor medical adherence
Predictors of High Risk Classification
• Poor adherence• Past psychiatric hospitalization• Mood disorder• Axis II disorder• Use of psychiatric medications• Hx of ETOH or drug detox• Hx of substance abuse• Lack of social support
Demographic Predictors of Risk
• Age (younger)• Marital status (single)• Gender (female)
Survival as a Function of Psych Risk
Neuropsychiatric Aspects of Immunosuppressive Agents
• Cyclosporine• Neoral (microemulsified
cyclosporine)• Tacrolimus (FK506)• Cellcept (Mycophenolat mofetil)• Corticosteroids
Cyclosporine
Dosage Forms: PO, IV, IMSerum Levels: 200-350ng/ml
(300-350ng/ml first 3 - 6 months)
Anxiety, delirium, hallucinations, seizures,tremor, paresthesias, hirsutism, cerebral blindness
May elevate Li levels by increasing absorption at the proximal tubules
Neoral (po Cyclosporine)
Dosage Forms: POSerum Levels: 200-350ng/ml (300-350ng/ml first 3-6 months)
For patients who are poor absorbers of cyclosporine-similar S/E profileBoth are nephrotoxic, neurotoxic, and hepatotoxic
Lithium, nefazadone, fluoxetine and fluvoxamine may elevate levelsSt. John’s wort may decrease levels.
Tacrolimus (FK 506)
Dosage Forms: PO, IVSerum Levels: 8-15ng/ml
Anxiety, delirium, insomnia, restlessness
Cellcept (mycohpenolat mofetil)
Dosage Forms: PO, IV
Anxiety, depression, somnolence, nausea, vomiting
Corticosteroids
Dosage Forms: PO, IV
Delirium, euphoria, depression, mania, insomnia, tremor, irritability, weight gain, memory impairment
Organ Donation
• Christopherson and Lunde – studied the families of heart donors.
• Found 4 motivational factors:– History of heart disease in the family– Sophisticated awareness of medical
needs (most donated other organs also)
– An expressed wish of the donor prior to death
– Attempt to give meaning to the loss of loved one
Issues in Living Related Donation
• Informed Consent• Psychological Assessment
– non-uniform• Motivation for Donation
– Altruistic (anonymous donation)– Familial or other Relationship– Coercion
• Financial • Rejection of donated organ
Future Challenges
• Expanding OHT to previously excluded patient populations (eg. elderly, mentally ill)
• Exploring the safety and efficacy of psychotropics in OHT patients
• Developing structured interventions that enhance compliance
• Xenotransplantation• Transplantation of the Human Face• Artificial Organs
fin