Catherine Crone

Psychiatric Aspects of Organ Transplantation in Critical Care

Intensive care unit teams are a critical part of the solid organ transplant process. The psychosocial issues involved during critical periods of transplantation are important for intensive care physicians and clinicians to understand to provide comprehensive care to transplant patients. This article provides a brief overview of transplant epidemiology, followed by a review of the psychosocial issues relevant to the phases of the transplant process. Considered are the pretransplant evaluation phase, psychiatric disorders in transplant patients, and cognitive impairments and delirium with additional issues specific to particular organs. Also covered are the side effects of immunosuppressive medications and special issues arising with living donors.

Cognitive Performance Enhancement: Misuse or Self-Treatment?.

Objective: This cross-sectional survey study examines the link between ADHD medication misuse and a positive screen for adult ADHD symptoms. Method: Surveys from 184 college student volunteers in Northern Virginia are collected and analyzed. Results: A total of 71% of ADHD stimulant misusers screen positive for ADHD symptoms. Misusers are 7 times more likely to be symptomatic for ADHD than those who do not misuse. Also, 87% of misusers indicate that they do so for academic reasons, and 76% believe that the misuse of the ADHD stimulants improve their grades. Conclusion: ADHD stimulant misuse in college students is found to be strongly linked to having symptoms of adult ADHD. The desire for cognitive performance enhancement in college students may be a form of self-treatment for undiagnosed ADHD. College students need more accessibility to medical diagnosis and treatment of adult ADHD to reduce the incidence of misuse in the future.

Psychiatric disorders as risk factors for adverse medical outcomes after solid organ transplantation.

Purpose of reviewGiven that the prevalence of psychiatric disorders in transplant candidates and recipients is substantially higher than in the general population, and that linkages between psychiatric disorders and medical outcomes for nontransplant-related diseases have been established, it is important to determine whether psychiatric disorders predict posttransplant medical outcomes. Recent findingsMost research has focused on the association between depression (both pretransplant and posttransplant) and posttransplant mortality. Some research has examined transplant-related morbidity outcomes, such as graft rejection, posttransplant malignancies, and infection. However, methodological limitations make it difficult to compare existing studies in this literature directly. Overall, the studies presented in this review indicate that psychiatric distress occurring in the early transplant aftermath bears a stronger relationship to morbidity and mortality outcomes than psychiatric distress occurring before transplant. SummaryThe literature on the impact of psychiatric conditions on the morbidity and mortality of solid organ transplant recipients remains inconclusive. More research is needed in order to investigate these associations among a broader range of psychiatric predictors, morbidity outcomes, and recipient populations. Until evidence suggests otherwise, we recommend frequent monitoring of psychiatric symptoms during the first year after transplantation to aid in early identification and treatment during this critical period of adjustment.

Rational Guidelines for Transplantation in Patients with Psychotic Disorders

This study investigated the outcomes of psychotic patients after transplantation to develop guidelines for rational decision-making with this group of transplant candidates. A survey was distributed to transplant programs in the United States, Canada, and Australia over a 2-year period, yielding 35 cases from 12 centers. Noncompliance resulted in rejection episodes in 14.7% of patients, with reduced function or graft loss in 11.8%. Noncompliance with immunosuppressant drugs was noted in 45.5% of those living alone versus 9.5% of patients living with someone. Suicide attempts were recorded in 35.7% of patients with psychotic symptoms in the year before transplantation, versus 5.9% for those without psychotic symptoms for 1 year before transplantation. Risk factors associated with problems after transplant included antisocial features, history of assault, borderline features, living alone, positive psychotic symptoms such as hallucinations and delusions, and a family history of schizophrenia.

Alcohol and Substance Use in Liver Transplant Patients

In this article the epidemiology of substance use and substance disorders in the United States and their association with liver disease are reviewed. The relevance of tobacco use and issues of candidacy as it pertains to substance use are discussed. The use of alcohol while on the waitlist and short sobriety are also addressed. The merits of monitoring of patients are discussed, and the outcomes of these patients after liver transplantation are examined. The article concludes with a summary of recommendations for clinicians working with these patients and possible future directions for both clinical care and research.

An Approach to the Patient with Organ Failure: Transplantation and End-of-Life Treatment Decisions

Organ transplantation offers an opportunity for extended survival and enhanced quality of life to patients with end-stage organ disease. Significant challenges are associated with both pre- and post-transplantation care, however, that require awareness of psychiatric issues in this patient population. Ventricular assist devices have added another dimension to patient care and to quality-of-life considerations. Unfortunately, effective incorporation of palliative care and end-of-life discussions is frequently overlooked during caretaking of these patients.

The Milestones for Psychosomatic Medicine Subspecialty Training

BACKGROUND The Accreditation Council of Graduate Medical Education Milestones project is a key element in the Next Accreditation System for graduate medical education. On completing the general psychiatry milestones in 2013, the Accreditation Council of Graduate Medical Education began the process of creating milestones for the accredited psychiatric subspecialties. METHODS With consultation from the Academy of Psychosomatic Medicine, the Accreditation Council of Graduate Medical Education appointed a working group to create the psychosomatic medicine milestones, using the general psychiatry milestones as a starting point. RESULTS This article represents a record of the work of this committee. It describes the history and rationale behind the milestones, the development process used by the working group, and the implications of these milestones on psychosomatic medicine fellowship training. CONCLUSIONS The milestones, as presented in this article, will have an important influence on psychosomatic medicine training programs. The implications of these include changes in how fellowship programs will be reviewed and accredited by the Accreditation Council of Graduate Medical Education and changes in the process of assessment and feedback for fellows.

Liver Transplant for Intentional Acetaminophen Overdose: A Survey of Transplant Clinicians׳ Experiences With Recommendations

BACKGROUND In the case of fulminant hepatic failure from acetaminophen, the ability to fully evaluate patients is often compromised. When hepatic recovery is not possible and liver transplantation (LT) is required, these patients present significant medical and psychosocial challenges to liver transplant teams. In this context, decisions about candidacy are often under emergency circumstances. To date, little empirical data exist to illustrate the experiences and approaches of those clinicians responsible for performing the psychosocial assessments of these LT candidates. METHODS We surveyed transplant mental health clinicians and discovered a wide range of opinions, approaches, and treatment planning when addressing acetaminophen overdose LT patients. RESULTS Although LT candidacy is commonly supported, there were distinct differences in considering the contributions of suicide risk factors. In addition, although poor post-LT outcomes (repeat suicide attempts and graft failure due to nonadherence) were known to have occurred in acetaminophen overdose LT cases, many respondents did not provide long-term mental health treatment to these patients following LT. CONCLUSION The results of the survey suggest that careful treatment planning in both the immediate and long term could improve the long-term care of these complex patients.