Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5258_Библиотеки_им_академика_М_И_Перельмана.pdf
357
Table 12.1
Psychological domains and factors measured by Stanford Integrated Psychosocial
Assessment for Transplant (SIPAT)
A.Patient’s readiness level and illness management (5 items)
Item 1: Knowledge and understanding of medical illness process (that caused specic organ
failure)
Item 2: Knowledge and understanding of the process of transplantation
Item 3: Willingness/desire for treatment (transplant)
Item 4: History of treatment adherence/compliance (pertinent to medical issues)
Item 5: Lifestyle factors (including diet, exercise, uid restrictions, and habits, according to
organ system)
B.Social support system level of readiness (3 items)
Item 6: Availability of social support system
Item 7: Functionality of social support system
Item 8: Appropriateness of physical living space and environment
C.Psychological stability and psychopathology (5 items)
Item 9: Presence of psychopathology (other than personality disorders and organic
psychopathology)
Item 10: History of organic psychopathology or neurocognitive impairment (i.e., illness or
medication induced psychopathology)
Item 11: Inuence of personality traits vs. disorder
Item 12: Effect of truthfulness versus deceptive behavior
Item 13: Overall risk of psychopathology
D.Lifestyle and effect of substance use (5 items)
Item 14: Alcohol use, abuse, and dependence
Item 15: Alcohol abuse—risk for recidivism
Item 16: Illicit substance abuse and dependence
Item 17: Illicit substance abuse—risk for recidivism
Item 18: Nicotine use, abuse, and dependence
Adapted from Maldonado etal. with permission [10]. Note that this study used outdated terms
from the DSM-IV to describe substance use disorders (section D), which have been revised in the
DSM-V [11]
intervention prior to transplant. Primary care providers should also seek to under-
stand what psychosocial risk factors their patients possess, as these may require
special attention in the post-transplant setting.
12.1.3 Prevalence andScreening ofSubstance Use Disorders
Prior toLiver Transplant
While affective disorders are common in patients listed for transplant of any organ
type, substance use disorders are more common in patients requiring liver transplant
[12]. Alcohol related liver disease is the most common cause of liver transplant
(30% in the US, 20% in Europe) followed by metabolic associated steatohepatitis
and hepatitis C cirrhosis, due most commonly to injection drug use [12] (see Chap.
5). Assessing patients for substance use is therefore critical to providing treatment
and support prior to and after transplant.
12 Mental Health intheAdult Solid Organ Transplant Recipient
358
While the SIPAT above includes a comprehensive substance use disorder diag-
nostic assessment, there are other pre-liver transplant risk stratication tools used
specically for patients with a history of alcohol use disorder [12, 13]. Most of these
tools aim to risk stratify patients based on their substance use history, insight, readi-
ness to quit, and other psychosocial factors. However, even with thorough assess-
ment, about 20–30% of patients transplanted for ARLD have a return to heavy
drinking [13]. Knowing a patient’s risk factors for resuming alcohol use is therefore
critical to supporting a patient with substance use disorder (SUD) in the primary
care setting following transplant.
12.1.4 Pre-transplant Pharmacology Considerations
Given the prevalence of mental health disorders among patients requiring trans-
plant, it is important to consider the role of psychotropic pharmacotherapy in this
population. While cognitive behavioral and other forms of therapy should be
offered, treatment with medications has been shown to improve outcomes: in a
study of liver transplant recipients, patients with affective disorders who were
treated with antidepressants at the time of transplantation had fewer episodes of
acute cellular rejection compared to those not taking antidepressants [2].
However, medication management in the pre- and post-transplant setting can
be complex. Organ failure often affects the pharmacokinetics of psychotropic
medications, requiring patients to be closely monitored and have medication
doses adjusted as their disease progresses. For example, most psychotropic
medications are hepatically cleared, necessitating dose decreases in patients
with liver failure [14]. In addition, other factors such as reduced protein binding
(liver and renal failure), increased extracellular uid (liver, kidney, and heart
failure), systemic vasoconstriction (heart and respiratory failure), carbon diox-
ide retention (respiratory failure), and other factors can impact the absorption
and distribution of medications in variable ways [14]. This underscores the
importance of tailoring medication management to each individual patient and
monitoring closely for toxicities. Furthermore, primary care providers should
anticipate the need for medication adjustment in the months to years following
transplant with improvement in organ function.
12.1.5 Importance ofPrimary Care
Patients undergoing transplant evaluation are more likely than the general popula-
tion to have a history of a mental health disorder. In the pre-transplant setting,
patients are often monitored very closely and provided signicant support by trans-
plant teams and clinic infrastructure. In the post-transplant setting as patients
recover, the access to those teams and resources often wanes. At this point, given the
G. Lenti etal.
359
relative scarcity of transplant centers and mental health providers across the US,
primary care providers are positioned to be the main source of guidance for patients’
mental health and other care, which can be an adjustment for both patients and pro-
viders. In supporting a transplant patient’s mental health care, a PCP could poten-
tially help improve the patient’s quality of life, medication adherence, and overall
health outcomes. The remainder of this chapter will focus on caring for the post-
transplant patient in the primary care setting.
12.2 Mental Health Disorders Post-transplant: Prevalence
andScreening
While many stressors exist for patients in the pre-transplant setting, solid organ
transplant (SOT) recipients face a new set of stressors, including recovering from
major surgery, taking and monitoring new medications, threat of organ rejection and
other illnesses that can result from immunosuppression, and eventually, integrating
themselves back into their prior lives with less medical oversight. Additionally,
mental health disorders in the post-transplant setting have implications for patient
morbidity and mortality. Understanding the prevalence of mental health disorders in
the post-transplant setting as well as appropriate screening for this population is
critical for primary care providers.
12.2.1 Prevalence ofAffective Disorders Post-transplant
Despite robust screening in the pre-transplant setting, the rates of clinically
signicant affective disorders in transplant recipients is still high compared to
the general population and other chronic disease cohorts. There is a wide range
of reported prevalence depending on screening instruments and diagnostic
thresholds. For example, studies have reported post-transplant prevalence of
depressive symptoms as 14% [15]–75% [16] for heart recipients, 5% [17]–75%
[18] for kidney recipients, 13.7% [19]–67% [20] for liver recipients, and 22%
[21]–30% [22] for lung recipients [23]. Fewer studies have examined the preva-
lence of anxiety disorders in post- transplant patients, though some studies esti-
mate up to 33% of patients experience some form of anxiety following transplant
[24]. Of anxiety disorders, post-traumatic stress disorder (PTSD) in transplant
recipients has been studied more extensively, with one meta-analysis noting the
prevalence of diagnosed PTSD being as high as 16% and questionnaire-assessed
PTSD symptoms as high as 46% [25]. Interestingly, higher rates of PTSD and
PTSD symptoms were found years out from transplant compared to the months
following transplant [25], which has implications for primary care providers, as
patients may no longer be following closely with their transplant teams by the
time these symptoms present.
12 Mental Health intheAdult Solid Organ Transplant Recipient
360
12.2.2 Impact ofAffective Disorders Post-transplant
Despite the high prevalence of affective disorders prior to and post-transplant, there
is mixed data on whether pre-transplant anxiety or depression predicts poor medical
or psychiatric outcomes post-transplant. Rosenberger etal. showed no correlation
between pre-transplant affective disorders and post-transplant outcomes [8],
whereas Delibasic etal. found that those with pre-transplant depression had higher
rates of medication non-adherence and hospitalization post-transplant [9]. Rogal
etal. showed that patients with pre-liver transplant depression required more post-
transplant psychiatric care without affecting medical outcomes [2], though later
found an association between pre-transplant depression and decreased survival [5].
Corruble etal. showed a decreased risk of graft failure and mortality in those with
depressive symptoms pre-transplant [7].
While individual studies have shown mixed results, a meta-analysis of 27 studies on
affective disorders in the transplant setting concluded that depression is associated with
an increase in post-transplant mortality [26]. In this meta-analysis, depression diagnosed
in the pre- or early post-transplant setting increased the relative risk of mortality by 65%
(RR=1.65, 95% CI 1.34, 2.05; 20 studies) [26]. Additionally, depression was associated
with increased risk of death-censored graft loss (RR=1.65, 95% CI 1.21, 2.26). The
reason for these associations is uncertain; possible mechanisms include reduced adher-
ence of post-transplant immunosuppressive medication or overall poorer lifestyle
behaviors, though more research is needed. Anxiety appeared to have a modest associa-
tion with mortality risk post-transplant, but the results were not statistically signicant,
in part due to the small number of published studies.
12.2.3 Screening forAffective Disorders inthePrimary
Care Setting
With regard to timing of mental health assessment (pre- versus post-transplant), one
study suggests that any occurrence of depression in the pre- or post-transplant time
period has the potential to increase mortality risk [26], while other studies have sug-
gested that psychiatric disease that occurs de novo after transplant puts patients at
higher risk of morbidity and mortality, possibly due to lack of coping skills or loss
of social support that had been cultivated in the pre-transplant setting [27]. It is also
notable that certain immunosuppressive drugs (e.g., glucocorticoids) have potential
side effects that can impact mental health and contribute to development of affective
disorders. As such, both the high prevalence of affective disorders in transplant
recipients and the risk these disorders may pose to long term health speaks to the
importance of screening for mood disorders in the post-transplant setting.
While there is still a dearth of literature on the outcomes of screening for affec-
tive disorders in the post-transplant setting, the Academy of Consult Liaison
Psychiatry (ACLP) proposes screening all organ transplant recipients for
G. Lenti etal.
361
depression. The ACLP best practice guidelines recommend screening solid organ
transplant recipients >18years of age once in the rst 6 months after transplanta-
tion, a second time before 1-year post-transplantation, and then yearly thereafter.
The guideline species that screening should be performed using the Patient Health
Questionnaire-9 (PHQ-9), which is easily administered in the primary care setting.
Other instruments validated in the transplant population may be used, including the
Hospital Anxiety and Depression Scale (HADS) or the patient-reported outcomes
measurement information systems-57 and -29 [23].
While guidelines show consensus for depression screening, the data around the
impact of anxiety on morbidity and mortality in transplant recipients is less conclu-
sive, and so too are guidelines around screening. Given that depressive and anxiety
disorders are highly comorbid, we recommend screening for generalized anxiety at
least yearly in transplant recipients using the General Anxiety Disorder-7 (GAD-7)
scale. While the United States Preventive Services Task Force (USPSTF) guidelines
suggest there is insufcient evidence for anxiety screening for patients over 65years,
we would recommend continuing yearly anxiety screening for transplant recipients
regardless of age. Additionally, given the more robust literature on PTSD and its
link to decreased quality of life and increased mortality [25], screening for PTSD
may be warranted in those with specic risk factors. For example, patients who
were consistently at higher risk of PTSD in published studies included those with
pre-transplant psychiatric illness and those with poor social support post-transplant.
Therefore, it may be important to specically explore pre-transplant mental health
and inquire about ongoing social support. Other potential risk factors included lon-
ger intensive care unit (ICU) length of stay, post-transplant complications, and post-
transplant depressive symptoms [25]. Prior studies of transplant recipients assessed
for PTSD using structured interviews, while others used questionnaires, including
the Impact of Events Scale-Revised (IES-R) and the PTSD CheckList Civilian
Version (PCL-C) [25]. While these questionnaires may be conducive to screening
for PTSD in the primary care setting, more work needs to be done to ascertain
whether such tools have validated use in SOT populations.
12.2.4 Prevalence andImpact ofSubstance Use Disorders
Post-liver Transplant
Given that alcohol related liver disease is among the most common reasons for liver
transplant, a return to prior substance use following transplant is of concern for clini-
cians. In a meta-analysis of studies published between 1983 and 2005 examining trans-
plant recipients with a pre-transplant history of substance use disorders, the average rate
of return to alcohol use was 5.6 cases per 100 patients per year for any alcohol use and
2.5 cases per 100 patients per year for heavy alcohol use [28]. In this study, poorer social
support, family history of alcohol use and pre-transplant abstinence <6months were
signicantly associated with a post-transplant return to use [28]. Return to use of other
12 Mental Health intheAdult Solid Organ Transplant Recipient
362
Fig. 12.1 Alcohol use trajectories from the point of transplant. This gure is adapted from research
by DiMartini etal. Groups 3 (n=13) and 5 (n=12) developed early onset moderate to heavy
drinking, whereas group 4 (n=15) had early low-level use that increased over time. Group 2
(n=55) drank low amounts infrequently, and group 1 (n=113) abstained altogether. Condence
bands are not shown [29]. (Reprinted with permission)
illicit substances was 3.7 cases per 100 patients per year, though rates were lower in
those who received liver transplant (1.9 cases) compared to those who received heart or
kidney transplants (6.1 cases) (note: the denitions of “illicit” may have varied between
studies) [28]. The return-to-use rate of substances other than alcohol for liver transplant
recipients is overall not well-studied.
While these yearly rates may seem low, when considered cumulatively over
many years, a substantial proportion of transplant recipients with prior substance
use disorders experience a return to use. DiMartini etal. studied alcohol use patterns
in liver transplant recipients over a 9-year period (Fig. 12.1) and found that the
majority (54%) remained completely abstinent, and approximately one-quarter
(26%) returned to drinking low amounts of alcohol infrequently. However, 19%
returned to moderate or heavy alcohol use, with some starting shortly after trans-
plant and others exhibiting progressively increased use several years out from trans-
plant. Those who drank moderately or heavily shortly after transplant were more
likely to report stress, pain, fatigue, and overall worse health. These patients also
more frequently had steatohepatitis or rejection on biopsy and were more likely to
experience graft failure [29].
12.2.5 Screening forSubstance Use Disorders
With the potential to return to substance use even many years post-transplant when
patients typically have less frequent contact with their transplant teams, it is vital
that primary care providers identify patients who have or are at risk for substance
G. Lenti etal.
363
Fig. 12.2 DSM-V diagnostic criteria for substance use disorder (SUD). Diagnosis requires two
criteria met for mild SUD, four for moderate, and six for severe [12]. (Reprinted with permission)
use disorders. They can further take an active role in assisting patients in managing
pain, stress and fatigue in the months to years following transplant.
For transplant recipients who were diagnosed with a substance use disorder prior
to transplant, the goal of a patient’s care team (including their PCP) should be to
help maintain remission from substance use. Oftentimes, patients are prepped in the
pre-transplant stage to expect discussion and monitoring of substance use post-
transplant [12], and PCPs can reinforce this plan as a means of supporting the
patient in their goals. We suggest brief direct inquiry about alcohol and substance
use in a non-judgmental manner at most PCP visits in the years following trans-
plant, with the goal to create ample opportunities to provide support, encourage-
ment and intervention if needed.
In the transplant population at large, including those without a history of substance or
alcohol use disorder, the AUDIT-C may be a suitable instrument to identify at-risk
drinking in routine post-transplant follow-up, though further validation is warranted
[30]. We agree with the USPSTF recommendation to screen all adults for unhealthy
alcohol use yearly (for which the AUDIT-C could also be utilized) and to provide brief
behavioral counseling to reduce unhealthy alcohol use. Note that diagnosis of a sub-
stance use disorder is not based on quantity or frequency of use, but rather on a person’s
dependency, inability to control use, and subsequent personal, social or health conse-
quences (see Fig.12.2 for Diagnostic and Statistical Manual of Mental Disorders-V
(DSM-V) diagnostic criteria). Taking further history to assess these behaviors is war-
ranted in someone who screens positive for unhealthy alcohol use.
12.3 Mental Health Disorders Post-transplant: Management
Treatment of mental health conditions can be complex in the solid organ transplant
population due to a variety of factors, including potential drug-drug interactions,
medical comorbidities, patients’ ability to tolerate or participate in interventions,
and the lack of supporting literature to guide treatment. Furthermore, access to
12 Mental Health intheAdult Solid Organ Transplant Recipient
364
psychotherapy and psychiatric care is limited in many areas of the United States
[31], and access to clinicians trained in transplant psychiatry specically is even
more scarce. As such, clinical intervention for mental health disorders will most
often take place in the primary care setting. In this section, we discuss unique man-
agement considerations for treating mental health disorders in SOT recipients, and
we review recommendations for treatment of common mental health disorders in
the primary care setting.
12.3.1 Psychological Approach toBehavioral Health
Assessment inaTransplant Recipient
Following transplant, a patient’s mental health may change signicantly and
suddenly due to several factors. Some changes are a direct result of physical
factors, such as the resolution of chronic physical symptoms or the adverse
effects of new medications. Other changes are a result of a shift in identity from
sick toward well and can also be simultaneously positive and negative. Standard
assessments of depressive and anxiety disorders are more challenging in this
population because their symptoms overlap with those of chronic organ disease
and medication adverse effects, and the range of possible patient behaviors
post-transplant can complicate outcomes. Therefore, a psychological frame-
work for assessing post-transplant mental health may be useful in identifying
clinically signicant functional decits.
For most patients, transplant produces a combination of new opportunities
and new demands, and a patient’s psychological experience can heavily depend
on the weight they assign to these positive and negative outcomes. In the pri-
mary care setting, a practical framework to understand patient behavior involves
assessing it as adaptive or maladaptive. An example of such a dyadic framework
in psychology is psychoanalyst Erik Erikson’s life stages, which proposes eight
stages of psychosocial development from birth to death [32]. Each stage
describes a virtue or skill attained through adaptation to age-appropriate chal-
lenges (Table12.2). For a transplant recipient, the Eriksonian skills get tested at
several points along the transplant timeline from onset of end-stage organ dis-
ease to beyond 10 years post-transplant [33]. In the next section, we will discuss
points in the transplant timeline that the patient may be under the direct care of
the primary care provider. Each point in the transplant timeline will be dis-
cussed in terms of the patient’s health stressors and their psychological response
(presence or loss of an Eriksonian skill). Examples of maladaptive responses
will be provided as targets of behavioral management. Behavioral management
in the primary care setting will be discussed following the timeline.
G. Lenti etal.
365
Table 12.2
Erik Erikson’s stages of psychosocial development
Years Conict Adaptive outcome Obstacles/trauma Poor outcome
0–1 Trust vs. mistrust:
is the world safe
and trustworthy?
Sure that needs will be
met by caregivers,
world is safe
Caregivers
neglectful or not
attuned to baby’s
needs
Suspicion of others,
anxiety, avoidance
1–3 Autonomy vs.
doubt: is it okay
to be me?
Physical task
independence,
self-control
Child is shamed
and has too many
restrictions
Self-doubt and shame
3–6 Initiative vs.
guilt: is it okay
for me to do
things?
Able to start things on
one’s own, sense of
purpose
Caregivers do too
many things for
child, child not
encouraged to try
Inadequate to do
things on one’s own,
only follows others’
lead
6–11 Industry vs.
inferiority: will I
be able to keep
up with others?
Sense of competency
and pride in activities
and skills
Unrealistic
expectations, pace
of learning is too
slow or too fast
Difculty organizing
and understanding
how things work
11–18 Identity vs.
confusion: who
actually am I?
Seeing self as unique,
multifaceted, yet
integrated in society/
community
Bullying, pressure
to conform to
caregiver
expectations
Impressionable,
negative sense of
self, identity tied to
others
18–30 Intimacy vs.
isolation: can I
love and be
loved?
Healthy friendships and
relationships, ability to
commit
Poor boundaries,
abuse (verbal,
emotional,
physical), chronic
rejection
Supercial or overly
intense relationships,
egocentric, lonely
30–65 Generativity vs.
stagnation: what
do I have of value
to offer the
world?
Feeling useful, create
things that will outlast
one’s own life
Inadequate time or
resources to focus
effort toward goals
Feeling purposeless,
distracted
65+ Integrity vs.
despair: do I feel
my life has been
meaningful and
well lived?
Appreciate
independence, remain
open-minded, humor,
empathy, humility,
value relationships,
satised with legacy
Potential not
reached,
unprepared for
decline in physical
function, goals
were not met
Signicant distress
about aging and
death, unmeaningful
efforts to prolong life
12.3.1.1 Before Transplant
During the onset of end-stage disease, evaluation for transplant, and registry on a
waitlist, patients face considerable uncertainty. Due to decline in function, acute
exacerbations of illness, hospitalizations, and intensive medical treatments, patients
must adapt to great change [33]. In this stage, failure to adapt may result in loss of
delity (or identity), generativity (or productivity), industry (or competence), and
initiative (or self-efcacy) [34].
Example: A single 55-year-old is a high-ranking corporate executive, has an
adult son, and is placed on hemodialysis for end-stage kidney disease. The patient
experiences identity loss when they must initially step down from their high rank to
12 Mental Health intheAdult Solid Organ Transplant Recipient
366
a less intensive role, loss of generativity when they eventually must take leave from
work entirely, and loss of self-efcacy when their son must help them by driving
them to hemodialysis.
Furthermore, their transplant center requires them to undergo extensive pre-
transplant workup with frequent clinic visits and lab work, serving as a test of their
competence. Adaptively, they may accept these changes with grace, nding a way
to remain satised with their time at home and follow through with all healthcare
tasks. Maladaptively, they may experience denial that they cannot work, delaying
their work leave or experiencing demoralization and self-loathing; they may hold on
desperately to independence and reject their son’s help, thus affecting their relation-
ship; or they may abate anxiety in the short term by avoiding the healthcare system,
missing appointments and decreasing adherence to treatment.
Other psychological responses are possible during this period. For example, due
to the swiftness with which patients are summoned for a transplant procedure,
patients with anxiety may feel ambivalent and even decline the offer of an immedi-
ately available organ [34]. A patient’s life before transplant may provide many clues
about psychosocial skill decits; offering supportive visits in this period will be of
diagnostic utility to the provider and therapeutic benet to the patient. If the primary
care provider’s rst meeting with the patient is post-transplant, it is still benecial
to take a history of their pre-transplant psychological experience to anticipate future
challenges the patient may uniquely face.
12.3.1.2 Early Post-transplant
The rst year after transplant has an increased risk of acute graft rejection, infection,
and rehospitalization. In addition, patients usually must complete formal or infor-
mal physical rehabilitation. This time period is when caregivers must intensively
support the patient at home. Although some patients experience immediate relief of
some of their pre-transplant symptoms, recovery of function is sometimes still grad-
ual. This period is also emotionally volatile, with some patients feeling elation
immediately following transplant, followed by uncertainty or fear [33]. In this stage,
failure to adapt may result in loss of hope (or trust in the world), loss of will (or
autonomy), and loss of delity (or identity).
Example: An 18-year-old high school athlete undergoes a heart transplant for
congenital hypertrophic cardiomyopathy and experiences an early episode of acute
graft rejection requiring rehospitalization. They have a strained relationship with
their parents because they are questioning their gender identity, and their parents are
not supportive of this exploration. They experience a loss of hope now that they
must be much more dependent on parents they did not already fully trust. Now that
there is fear of additional acute graft rejection episodes, they experience loss of
appropriate autonomy if their parents are either too restrictive or too demanding of
them, and loss of delity as they must stop school sports. Adaptively, they may
make efforts to mend their strained relationships or seek more trustworthy ones, try
to master independence in managing their own medications, read and learn about
G. Lenti etal.