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Transplant Psychiatry Curley L. Bonds, MD Associate Professor & Chair Department of Psychiatry & Human Behavior Charles Drew University School of Medicine.

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Presentation on theme: "Transplant Psychiatry Curley L. Bonds, MD Associate Professor & Chair Department of Psychiatry & Human Behavior Charles Drew University School of Medicine."— Presentation transcript:

1 Transplant Psychiatry Curley L. Bonds, MD Associate Professor & Chair Department of Psychiatry & Human Behavior Charles Drew University School of Medicine Associate Clinical Professor & Vice-Chair Department of Psychiatry David Geffen School of Medicine at UCLA

2 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


4 Scope of Solid Organ Transplantation Kidney Kidney/Pancreas Liver Heart Lung Small Bowel Special Senses (Cornea, Cochlea, etc.) Limbs (Face, Hand)

5 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)

6 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

7 The Transplant Team Transplant Surgeon Internists & Sub-specialists Psychiatrist/Psychologist Transplant Coordinators/Nurses Social Worker Ethicists/Pastoral Services Community Members

8 Pre-Transplant Evaluation Psychosocial Assessment –Past Psychiatric History –Current psychiatric symptoms/illness –Psychotropic use –Substance use history –Social support –Cognitive evaluation –Understanding & Knowledge

9 Determining Transplant CandidacyPsych Social Bio Assessment

10 Biopsychosocial Screening Suitability for Transplant Compliance Social Supports Understanding & Knowledge Recipients History and Habits

11 The Transplant Patient Biological, psychiatric and ethical issues in organ transplantation Ed. By Paula Trzepacz & Andrea DiMartini © Cambridge University Press 200

12 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 patients ability to maintain abstinence Help the team get to know the patient as a person to provide better care

13 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

14 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

15 Psychological evolution and assessment in patients undergoing OHT Triffaux, Wauthy, Bertrand et al. European Psychiatry 2001: 16: 180-5

16 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

17 Measures Employed Speilbergers State-Trait Anxiety Inventory Beck Depression Inventory Perceived Social Support Scale Toronto Alexithymia Scale Personal Reaction Inventory

18 Pre-operative pathology 41% (n=9) of patients had some DSM IV Axis I Diagnosis 18% (n=4) presented with an Axis II condition

19 Psychosocial Risk Factors for Noncompliance History of substance abuse Age <30 Experiencing economic or psychosocial stress Surman 1992

20 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

21 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)

22 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

23 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

24 Psychotic Disorders as a Contraindication to OHT at US Transplant Programs Absolute Contraindication Relative ContraindicationIrrelevant Active Schizophrenia 92.3%5.1%2.6% Controlled Schizophrenia 33.3%51.3%15.4% Levinson & Olbrisch, 2000

25 Affective Disorders as a Contraindication to OHT at US Transplant Centers Absolute Contraindication Relative ContraindicationIrrelevant Current Affective Disorder 44.9%47.4%7.7% Hx of Affective Disorder 5.1%62.8%32.1% Levinson & Olbrisch, 2000

26 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 SI75.6%17.9%6.4%

27 Mental Retardation/IQ as a Contraindication to OHT at US Transplant Centers Absolute Contraindication Relative ContraindicationIrrelevant MR IQ >7025.6%59.0%15.4% MR IQ <7074.4%19.2%6.4% Levinson & Olbrisch, 2000

28 Dementia as a Contraindication to OHT at US Transplant Centers Absolute contraindication: 71.8% Relative contraindication: 23.1% Irrelevant: 5.1% Levinson & Olbrisch, 2000

29 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

30 Assessment Tools TERS - Transplant Evaluation Rating Scale PACT – Psychosocial Assessment of Candidates for Transplantation

31 Predictive Value of Pre-Op Assessment Psychiatric Disorders and Outcome Following Cardiac Transplantation Skotzko, et al., J. of Heart and Lung Transplantation, 1999

32 Predictive Value of Pre-Op Assessment 107 OHT recipients Transplanted Jan. 90 - Sept. 91 Retrospective chart review Medical outcomes measured: 1 year survival rehospitalizations infections rejections

33 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

34 Guilt Anxiety Depression Disability Waiting Pre-Operative Issues

35 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 1B Pt requires: a circulatory assist device or admission to an acute care hospital and continuous infusion of IV inotropes

36 UNOS Heart Allocation Policy Status 2A Patient requires continuous infusion of IV inotropes Status 2B Patients needing a heart transplant but not meeting criteria for 1A, 1B or 2A

37 Pre-Operative Interventions Transplant Support Group Internet/Online Support Groups National Heart Association Transplant Olympics Individual Psychotherapy Antidepressants/Anxiolytics

38 Body Image New Meds Role Strain Financial Rehabilitation Post-Operative Issues

39 1 st Three Years after OHT 191 OHT recipients were followed for 3 years: –Major Depressive Disorder25.5% –Adjustment Disorders20.8% –PTSD-T17% –Any Disorder38% Dew, Kormos, et al Psychosomatics2000

40 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.


42 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

43 UCLA Experience

44 UCLA Alternate Transplant List

45 UCLA Experience: Axis II Pathology

46 Psychiatric Evaluations of Heart Transplant Candidates: Predicting Post-Transplant Hospitalizations, Rejection Episodes, and Survival Owen, Bonds, Wellisch Psychosomatics 2006: 47:213-222

47 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

48 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

49 Outcome Measures Re-hospitalization/Rejection Infection Death

50 Methods 108 OHT recipients followed for average of 970 days Transplanted between 1997 and 2000 >18 years old Followed by UCLA Heart Transplant Team

51 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

52 Risk Assessment Good Candidates – 50% High Risk- 11.1%

53 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

54 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

55 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

56 Demographic Predictors of Risk Age (younger) Marital status (single) Gender (female)

57 Survival as a Function of Psych Risk

58 Neuropsychiatric Aspects of Immunosuppressive Agents Cyclosporine Neoral (microemulsified cyclosporine) Tacrolimus (FK506) Cellcept (Mycophenolat mofetil) Corticosteroids

59 Cyclosporine Dosage Forms: PO, IV, IM Serum 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

60 Neoral (po Cyclosporine) Dosage Forms: PO Serum Levels: 200-350ng/ml (300-350ng/ml first 3-6 months) For patients who are poor absorbers of cyclosporine-similar S/E profile Both are nephrotoxic, neurotoxic, and hepatotoxic Lithium, nefazadone, fluoxetine and fluvoxamine may elevate levels St. Johns wort may decrease levels.

61 Tacrolimus (FK 506) Dosage Forms: PO, IV Serum Levels: 8-15ng/ml Anxiety, delirium, insomnia, restlessness

62 Cellcept (mycohpenolat mofetil) Dosage Forms: PO, IV Anxiety, depression, somnolence, nausea, vomiting

63 Corticosteroids Dosage Forms: PO, IV Delirium, euphoria, depression, mania, insomnia, tremor, irritability, weight gain, memory impairment

64 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

65 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

66 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

67 fin

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