Owen S. Surman

Pretransplant depression, antidepressant use, and outcomes of orthotopic liver transplantation.

Depression is a common problem among patients awaiting organ transplantation, but little is known about the impact of depression and its treatment on the outcomes of liver transplantation. In this retrospective cohort analysis, we studied all patients over 18 years of age who underwent liver transplantation during a 5‐year period (2004‐2008) at a single center. Among 179 recipients, 65 patients had depression, as defined by a health care provider assessment, before transplantation. Depression was defined as past or active depression or an adjustment disorder. The associations between pretransplant depression and various outcomes (time to death, graft failure, first acute cellular rejection episode, first infection, and first rehospitalization) were assessed. In the entire sample, more patients with depression required posttransplant psychiatric care (37% versus 18%); the adjusted hazard ratio was 2.28 (1.27‐4.11). The rates of other outcomes, including hospital readmission, acute cellular rejection, graft failure, mortality, and infection, were similar for patients with depression and patients without depression. Among those with depression, patients on antidepressants at the time of transplantation had acute cellular rejection less frequently than those not taking antidepressants (13% versus 40%); the adjusted hazard ratio was 0.14 (0.03‐0.62). The rates of other outcomes were similar between these 2 groups. These data indicate that depression affects posttransplant psychiatric morbidity but not other medical outcomes of liver transplantation. Pharmacological treatment of depression may significantly reduce the incidence of acute cellular rejection in patients undergoing liver transplantation. However, future prospective studies of mental health and liver transplantation are required to definitively assess the effects of antidepressant medications on medical outcomes. Liver Transpl, 2011.

Psychiatric Care of Patients Undergoing Organ Transplantation

Transplantation provides life-saving therapy to critically ill patients with end-stage organ failure. We found that the specialized knowledge of mental health clinicians and physicians, committed to the evaluation and management of transplant recipients, is essential for the optimal care of these patients who require a life-long regimen of immunosuppressive medication and dependency on the transplant team. Critical issues requiring psychiatric input are frequently encountered in the following areas (1) patient selection and informed consent; (2) recognition and pretransplant treatment of psychiatric disorders; (3) substance or alcohol abuse; (4) compliance with medical regimens; (5) posttransplant psychosis; and (6) immunosuppressive/psychiatric drug-drug interactions. This review focuses on the priorities in psychological and psychiatric care of these unique patients.

Immunological Response to Stress in Agoraphobia and Panic Attacks

The authors studied in vitro immune function as measured by lymphocytic proliferative response to mitogen stimulation in 36 patients with agoraphobia and panic attacks who were participating in a double-blind placebo-controlled psychopharmacological study of anxiety disorder. No significant difference in immune status was observed between panic patients and healthy controls.

Is this live-organ donor your patient?

The transplant community is in the midst of an ethical reflection regarding the manner in which live-organ transplantation should be practiced. There is a fundamental aspect to be addressed and reaffirmed. It is the doctor-patient relationship between the transplant surgeon and the live-organ donor. This relationship brings a mutual responsibility to the physician and the donor patient to each other, which should not be abrogated by the claim of donor autonomy nor the obligation fostered by the recipient’s needs. If equipoise is not affirmatively achieved in the risk-benefit calculation for the donor and the recipient, then sound medical judgment should override all other concerns.

Psychosomatic aspects of liver transplantation.

Forty patients received orthotopic liver transplants at Massachusetts General Hospital between May 21, 1983 and July 21, 1987 (mean follow-up: 64 weeks, range: 2-186 weeks). Twenty-seven patients (68%) were living as of July 21. Among survivors, 15 (56%) returned to full activity; and 7 (26%) were partially rehabilitated. Five patients were rehospitalized or recently transplanted. Successful outcome occurred most often among those who came to transplant early in the course of illness. All adults experienced preoperative anxiety and 17 (50%) of adults had some degree of hepatic encephalopathy. Following operation, 8 adults (24%) were referred for treatment of depressive disorder typically associated with deterioration of hepatic status, infectious complication or recurrence of cancer. Medical noncompliance required psychiatric intervention in 3 cases. Other psychiatric events an increasingly successful intervention of major scope and affords meaningful survival to many patients whose liver disease allow less than a year of life. Psychiatric consultation is an essential support to the transplant program.

Liver transplantation: Psychiatric considerations

Abstract Alcoholism is the leading cause of liver failure. Because of the compliance requirements of liver transplantation, a candidate at our hospital must have participated in an alcohol treatment program with at least one year of established sobriety. Other major selection criteria are the absence of severe extrahepatic disease and the presence of a reasonable degree of social support. The principal postoperative psychiatric problems in our series were organic brain syndrome, depression, and anxiety. Approaches for their management are described. As of September 1987, 24 of 40 patients who underwent liver transplant remained alive from seven to 191 weeks after the operation, and 16 of them were in good general health and fully rehabilitated.

A Double-Blind, Placebo-Controlled Study of Oral Acyclovir in Postherpetic Neuralgia

Twenty-one patients with postherpetic neuralgia of two- to 84-months duration participated in a double-blind, placebo-controlled study of oral acyclovir. Pain perception was assessed with the Melzack Pain Questionnaire at baseline and at two-to six-week intervals during the ensuing six months. Clinically significant pain reduction occurred in eight patients: four received acyclovir, and four received a placebo. Several treatment strategies have been advocated for relief of postherpetic neuralgia. Results of the present study demonstrate the need for a double-blind, placebo-controlled paradigm to substantiate the efficacy of new clinical approaches. The same caveat applies to the more common syndromes encountered in psychiatric practice.

Ethical dichotomies in organ transplantation a time for bridge building

Rapid advances of the past 15 years have resolved many of the technical and immunologic limitations to organ transplantation. With the success rates that can now be achieved, there is increased attention to the limited supply of donor organs and to cost considerations, the remaining obstacles to wide application of organ transplantation. Competition for organs and for funding demands greater focus on patient selection and resource allocation. As Charles Taylor, philosopher and political scientist, has written, ethical formulations inevitably conflict when each is taken to its logical end point. In the 1960s, a life boat ethics framework predominated for selection of transplant recipients. The opposing egalitarian framework of recent decades has allowed for enrollment of older transplant recipients and those with histories of substance abuse. In the United States, alcoholic liver disease has been the most common indication for orthotopic liver transplantation since 1987. Among those awaiting transplantation, urgency has been a priority over time waiting. But many potential transplant candidates who are young and who appear relatively stable die while waiting. Despite the shortage of cadaveric organs, physicians and ethicists have for the most part eschewed rewards or reimbursement for living related organ donation. Such conventions are a function of the prevailing zeitgeist and are susceptible to a paradigm shift in parallel with overall changes in societal regulation of medical practice. Theorists and practitioners are immersed in the trends of the day and the approach at each moment seems preferable to that of the moment preceding. From a practical standpoint it may be possible to bridge disparate ethical constructs. For example, in the wait for solid organ transplantation, a bicameral approach could alternatively accommodate time waiting and urgency. Selection of older patients and those with a past substance abuse history could be limited to those with the best prognosis for compliance and posttransplantation quality of life. Living organ donors and families of nonliving donors could receive incentives of a noncoercive nature that would stimulate participation without sacrificing altruism. Creative approaches are needed to improve fairness and efficacy in solid organ transplantation.

Possible Immunological Effects of Psychotropic Medication

Psychoactive drugs provide an essential intervention in the care of organ transplant recipients, yet little is known of their effect on immunological function. Human and animal data on immunological effects of neuroleptic (e.g., haloperidol, phenothiazines) and antidepressant agents (e.g., tricyclic antidepressants, fluoxetine) lead to conflicting hypotheses. Lithium carbonate acts through the phosphoinositide system and has a bipolar effect on neuronal activity. Lithium is known to have immune-enhancing properties and is difficult to administer in the peritransplant period but nonetheless deserves study for possible beneficial effects on allograft function.

Microcomputer-Assisted Relaxation

The present pilot study was designed to test the effectiveness of a microcomputer program developed by the authors to induce relaxation and focused attention, which are common to most clinical stress-reduction and hypnotic procedures. A nonclinical sample of 20 adults used the program on an APPLE lie computer in two 30-min. sessions in a within-subjects design. Repeated measures analyses of variance showed significant decreases in the Spielberger State Anxiety Scale and on a visual analog anxiety scale. Limitations and implications of the study are discussed.