Sheila G. Jowsey

Analysis of factors that predict alcohol relapse following liver transplantation

Alcoholic liver disease has become a major indication for liver transplantation in the United States. Factors that predict alcohol relapse after liver transplantation are poorly defined. The aim of our study was to identify predictors of alcohol relapse in patients undergoing liver transplantation for alcoholic liver disease. One hundred and eleven patients undergoing liver transplantation for alcoholic liver disease between 1985 and 1999 were identified from our database. Patients were selected for liver transplantation if their risk of relapse was felt to be low by the transplant team. A chart review was conducted to determine if relapse had occurred, the presence or absence of factors that were thought to predict relapse, and survival. Demographic and psychosocial variables were analyzed using univariate and multivariate logistic regression to identify independent predictors of relapse. The median duration of abstinence before liver transplantation was 15 months (range: 1–120). Hepatitis C virus was present in 64% of patients. A family history of alcoholism in a first‐degree relative was identified in 38%, and 78% received treatment for alcoholism before liver transplantation. The mean duration of follow‐up was 44.1 ± 3.7 months. There were 29 deaths (26%) overall. Seventeen patients (15%) returned to alcohol use. On multivariate analysis a family history of alcoholism was found to be an independent predictor of alcohol relapse (P= .03). Further prospective studies are needed to examine this association in greater detail to provide targeted treatment for alcoholism both before and after liver transplantation. (Liver Transpl 2004;10:408–411.)

Psychosocial Challenges in Transplantation

The authors review the psychosocial aspects of transplantation. They first review psychosocial risk factors that place transplant patients at higher risk for noncompliance and negative outcomes. They then discuss what assessments should be included in a pretransplantation psychosocial evaluation. Goals of the psychosocial evaluation include selection of candidates most likely to benefit from transplantation and identification of areas for psychosocial intervention, both before and after transplantation. The assessment should address the patient’s premorbid psychiatric state, past adaptation to stressors, history of compliance with treatment, substance abuse history, and level of social support, including community and faith-based support systems. Results of psychometric assessments may be helpful when considered in conjunction with a clinical interview and other sources of information about the patient. It may also be helpful to use a screening tool developed specifically to evaluate psychosocial factors relevant to transplantation, such as the Psychological Assessment of Candidates for Transplantation (PACT) scale and the Transplantation Evaluation Rating Scale (TERS). The authors then review issues related to psychopharmacologic interventions in transplant patients, including the use of antidepressant medication pre- and post-transplant, strategies for avoiding delirium associated with immunosuppressive medications immediately post-transplantation, neuropsychiatric symptoms associated with interferon alpha therapy for hepatitis C, and interactions between over-the-counter and herbal agents (e.g., St. John’s Wort) and immunosuppressive agents. Although limited research has been done on nonpharmacologic interventions, such as transplant support groups, it appears that certain types of group therapy, in particular, cognitive-behavioral groups that target specific risk factors such as depression, distress, and compliance, may also offer promising approaches for dealing with the problems of transplant patients. The authors then focus on two special situations that create particular problems for transplantation teams: liver transplantation in patients with alcoholic liver disease (ALD) and obesity in transplant patients. The authors conclude that the prognosis for patients with ALD who receive liver transplantation is similar to that of non-alcoholics and that alcoholism is not a contraindication for liver transplantation. However, careful preliminary psychosocial assessment is essential to review candidates for factors that are predictive of relapse, while close follow-up post-transplantation can help improve outcomes. It appears that obesity can increase the risk of negative outcomes in transplant patients, although there is currently no consensus on the use of obesity as an exclusion criteria. Interventions that take into account the special psychological and medical needs of transplant patients need to be developed for treating obesity both pre- and post-transplantation. Improved strategies for identifying high-risk patients and finding ways to intervene both pre- and post-transplantation can not only help lengthen transplant recipients’ life spans, but also improve their adaptation to transplantation and lead to improved quality of life.

Pseudoseizures after epilepsy surgery

Seizure surgery for medically intractable partial epilepsy in selected patients usually results in dramatically improved seizure control. However, the authors present six patients who, after surgery for refractory complex partial seizures, postoperatively experienced pseudoseizures (also known as nonepileptic seizures), confirmed with EEG monitoring. Three of these patients also had nonepileptic seizures preoperatively that coexisted with their partial epilepsy. Psychiatric assessment revealed that this patient group had several characteristics in common, which suggests that preoperative psychiatric consultation may help identify those patients at risk for developing nonepileptic seizures. Treatment strategies with anticonvulsant medications and behavioral therapy are reviewed.

Psychosocial factors in living organ donation: clinical and ethical challenges

Living donor surgery has come to the forefront of public attention because increasing numbers of potential donors respond to the organ shortage. Because of several factors including decreased morbidity from donor surgery, online resources appealing for organs, and increased publicity about donation, new populations of unrelated donors are seeking evaluation for donor surgery. However, concern about potential coercion of vulnerable individuals, the potential for adverse psychosocial outcomes, and recent reports of donor deaths have reinvigorated discussion within the medical community about how best to assess donors. Research on the long-term quality of life outcomes for donors suggests that most donors are satisfied with their decision to donate. Small single-center studies on psychosocial outcomes have reported psychiatric sequelae after donor surgery. Little is known about the psychosocial outcomes for donors who are psychosocially excluded from donating. A multidisciplinary team approach, including social work and psychiatry evaluations, allows for the comprehensive assessment of important areas including motivation and expectations about surgery, current and past psychiatric conditions, history of substance or alcohol abuse, family support, understanding of the risks and alternatives of donor surgery for the donor and recipient, and motivation for donation including any evidence of coercion.

Emotional and Financial Experiences of Kidney Donors over the Past 50 Years: The RELIVE Study

BACKGROUND AND OBJECTIVES Most kidney donors view their experience positively, but some may experience psychosocial and financial burdens. We hypothesized that certain donor characteristics, poor outcome of the recipient, negative perceptions of care, and lack of support may be associated with poor psychosocial outcomes for donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Renal and Lung Living Donors Evaluation Study (RELIVE) examined long-term medical and psychosocial outcomes for kidney donors (at three U.S. transplant centers) who donated between 1963 and 2005. Standardized questionnaires evaluated donor perspectives, recovery time, social support, motivation, financial impact, insurability after donation, and current psychological status. Questionnaires were mailed to 6909 donors. RESULTS Questionnaires were returned by 2455 donors, who had donated 17 ± 10 years earlier (range, 5-48 years), a response rate of 36%. Most (95%) rated their overall donation experience as good to excellent. Rating the overall donor experience more negatively was associated with donor complications, psychological difficulties, recipient graft failure, and longer time since donation. Nine percent (n=231) reported one or more of the following poor psychosocial outcomes: fair or poor overall donor experience, financial burden, regret or discomfort with decision to donate, or psychological difficulties since donation. Recipient graft failure was the only predictor for reporting one or more of these poor psychosocial outcomes (odds ratio, 1.77; 95% confidence interval, 1.33 to 2.34). Donors with lower educational attainment experienced greater financial burden. One of five employed donors took unpaid leave; 2% reported health and life insurability concerns. CONCLUSIONS Although the majority of donors viewed their overall donation experience positively, almost 1 in 10 donors reported at least one negative consequence related to donation. Recipient graft failure was associated with poor psychosocial outcome, defined as one or more of these negative consequences. Some donors were financially disadvantaged, and some experienced insurance difficulties. Interventions to avoid negative psychosocial and financial consequences are warranted.

Emotional Well-Being of Living Kidney Donors: Findings From the RELIVE Study

Following kidney donation, short‐term quality of life outcomes compare favorably to US normative data but long‐term effects on mood are not known. In the Renal and Lung Living Donors Evaluation Study (RELIVE), records from donations performed 1963–2005 were reviewed for depression and antidepressant use predonation. Postdonation, in a cross‐sectional cohort design 2010–2012, donors completed the Patient Health Questionnaire (PHQ‐9) depression screening instrument, the Life Orientation Test‐Revised, 36‐Item Short Form Health Survey and donation experience questions. Of 6909 eligible donors, 3470 were contacted and 2455 participated (71%). The percent with depressive symptoms (8%; PHQ‐9 > 10) was similar to National Health and Nutrition Examination Survey participants (7%, p = 0.30). Predonation psychiatric disorders were more common in unrelated than related donors (p = 0.05). Postdonation predictors of depressive symptoms included nonwhite race OR = 2.00, p = 0.020), younger age at donation (OR = 1.33 per 10 years, p = 0.002), longer recovery time from donation (OR = 1.74, p = 0.0009), greater financial burden (OR = 1.32, p = 0.013) and feeling morally obligated to donate (OR = 1.23, p = 0.003). While cross‐sectional prevalence of depression is comparable to population normative data, some factors identifiable around time of donation, including longer recovery, financial stressors, younger age and moral obligation to donate may identify donors more likely to develop future depression, providing an opportunity for intervention.

The psychological assessment of candidates for reconstructive hand transplantation

Standardized psychological assessment of candidates for reconstructive hand transplantation (RHT) is a new approach in transplantation medicine. Currently, international guidelines and standardized criteria for the evaluation are not established. Patients suffering from the loss of a hand or an upper extremity have to cope with multiple challenges. For a selected group of patients, RHT represents an option for restoring natural function and for regaining daily living independence. The identification of at‐risk patients and those requiring ongoing counseling due to poor coping or limited psychological resources are the primary focus of the psychological assessment. We have developed the ‘Innsbruck Psychological Screening Program for Reconstructive Transplantation (iRT‐PSP)’ which utilizes a semi‐structured interview and standardized psychological screening procedures and continuous follow‐up ratings. Between January 2011 and October 2011, four candidates were evaluated using the iRT‐PSP. Psychological impairments including social withdrawal, embarrassment, reduced self‐esteem, and a depressive coping style were identified and poor quality of life was reported. The motivation for transplantation was diverse, depending on many factors such as bi‐ or unilateral impairment, native or accidental loss of hand, and social integration.

Satisfaction With Life Among Living Kidney Donors: A RELIVE Study of Long-Term Donor Outcomes

Background Little is known about living kidney donors’ satisfaction with life (SWL) after donation. We compared donors’ SWL to previously reported general population samples and investigated predictors of donors’ SWL. Methods Three transplant centers mailed questionnaires to assess SWL, physical health, optimism, retrospective evaluation of the donation experience, and demographic characteristics to living kidney donors’ homes between 2010 and 2012. Two thousand four hundred fifty-five donors who were between 5 and 48 years from the time of their donor surgery completed the questionnaire. Results Eighty-four percent of donors were satisfied with their lives (scores≥20 on the Satisfaction With Life Scale). Donors were at least as satisfied with their lives as previously reported general population samples. After adjusting for physical health, optimism, and demographics, donors’ SWL was significantly associated with donors’ recalled experience of donation. Social support and positive effects of the donation on relationships predicted greater SWL. Financial difficulties associated with donation and longer recovery times predicted lower SWL. Recipient outcomes were not significantly related to donor SWL. Discussion Limitations include the lack of predonation SWL data, potential bias in postdonation SWL because of the situational context of the questionnaire, and a sample that is not representative of all U.S. living kidney donors. Nonetheless, strategies focused on improving the donation experience, particularly related to recovery time, financial issues, and social support, may result in greater SWL after donation.

Seligman's theory of attributional style: optimism, pessimism, and quality of life after heart transplant.

Context— Posttransplant quality of life can be significantly affected by personality characteristics identified before transplant. Objective— Although overall quality of life in heart transplant patients improves after transplant, many studies reveal poorer mental health outcomes after transplant. We aimed to determine whether transplant recipients with an optimistic explanatory style had improved quality of life, fewer depressive symptoms, and increased survival. Design— We reviewed 68 patients who had completed a Minnesota Multiphasic Personality Inventory a mean of 2 years before transplant and examined associations between scores on the Optimism-Pessimism scale, survival rates, and results from the Health Status Questionnaire nearly 4 years after transplant. Results— Optimism was significantly associated with higher quality of life even after age (at the time of transplant), sex, depression score before transplant, time from the personality inventory to transplant, and time from transplant to the Health Status Questionnaire were controlled for. Furthermore, a pessimistic explanatory style was significantly associated with self-reported depressive symptoms, even after depression before transplant was adjusted for. Neither optimism nor pessimism was associated with length of survival. Conclusions— Pretransplant patients with a pessimistic explanatory style reported depressive symptoms nearly 5 years later. Furthermore, over the same time span, patients with an optimistic explanatory style described a significantly higher quality of life than the pessimists described.

Psychological aspects of hand transplantation.

Purpose of reviewPsychosocial aspects are important indicators for reconstructive hand transplantation (RHT). They warrant further research attention given the influence of psychosocial factors on the success of RHT. This review will contrast RHT with solid organ transplantation, provide information to guide selection of RHT candidates and ethical implications, share information on psychological outcomes, and address the importance of a multicenter research approach. Recent findingsPreviously published RHT reports have tried to identify psychosocial factors that are essential to guide selection of RHT candidates and that predict psychosocial outcomes. These issues in RHT are receiving increased attention, but standardized psychosocial evaluation and follow-up protocols are still needed. Recent study highlights the potential for a multicenter research approach that uses standardized assessment strategies and also emphasizes the need for a shared assessment approach to understand psychosocial outcomes. SummaryRHT combines the technical rigors of hand surgery and microsurgery with the complex multidisciplinary care that defines modern transplantation medicine. As recent work has provided a more complete picture of the complexities of the psychosocial factors in RHT, a psychosocial assessment protocol developed with input across the centers currently performing this procedure would capitalize on the collective diverse clinical experiences and standardize the assessment and follow-up protocol. With such standardized procedures in place, psychosocial risk factors for both poor psychosocial and medical/surgical outcomes can be identified which can inform the selection or preparation of future candidates.