Advanced medical procedures are expensive, often risky, and pose both short- and long-term challenges for those who receive them. Psychiatric assessment prior to many procedures is often requested, either due to regulations or convention. However, the evidence in favor of these evaluations ranges from some obvious benefits to near conjecture, and while common sense and clinical judgment can lead evaluators to focus on those aspects of the patient’s life that seem relevant, evidence (where available) should guide the work. Organ transplantation and bariatric surgery are two examples of these high-stakes medical interventions that involve psychiatry and related mental health fields during the evaluation process. A review of some of the evidence and areas of uncertainty follows.
Organ transplantation has become a standard treatment in the United States for end-stage organ failure. The United Network for Organ Sharing (UNOS), the governance organization for transplant, reports that transplants have increased by 18% over the 10 years ending in 2011 (see Table 1). Despite this significant increase, there are still more than 115,000 people listed for transplant in the US as of October 2012.1
Table 1. Transplants in the United States in 2011
Due to the shortage of organs, UNOS requires a comprehensive assessment of candidates prior to listing to ensure that recipients can maximize the utility of the transplants. UNOS requires a psychosocial evaluation as part of the pre-transplant assessment to further optimize selection of candidates. Although accurate prediction of posttransplant outcomes remains elusive, a number of tools for assessment and risk factors for adverse outcomes have emerged.
Untreated Psychiatric Disorders
A few core areas are consistently assessed when patients are being considered for transplant. Untreated psychiatric disorders can worsen after transplant and should be screened for during the pre-transplant period. Affective and anxiety disorders are the most common findings and, if symptoms are severe, should be vigorously treated prior to listing. In particular, patients with significant depressive symptoms or current or recent suicidal ideation should be assessed carefully for transplant. Although one recent analysis did not find depression or anxiety to significantly predict post-transplant outcomes,2 monitoring and treating symptoms presumably would lessen suffering overall, including the discomfort and uncertainty associated with the procedure.
Even more common in this population are substance use disorders. Rates of alcohol or drug misuse are high in the liver transplant population, as the two leading indications for liver transplant in the US, hepatitis C and alcohol-related liver disease, are closely linked to injecting drug use and alcohol misuse, respectively.
Although there are no absolute guidelines regarding abstinence, programs generally require 6 months of sobriety prior to listing.3 Shorter periods of abstinence are associated with an increase in relapse rates, as well as an increase in the return to clinically significant use after transplant, and generally the longer a patient can remain abstinent prior to transplant the greater the likelihood that they will remain so afterward.4
Thus, patients should be referred to treatment programs to support their abstinence prior to listing. Once the patient is enrolled, those programs can provide updates to the transplant team about the patient’s progress and attendance to help ensure abstinence and increase the candidate’s chances for success. To circumvent issues of privacy, patients should agree to the release of information prior to starting treatment, so communication between the transplant team and the addiction professional can happen routinely.
After transplant, patients run the risk of organ rejection if they do not manage their health. Up to 25% of posttransplant deaths after the initial recovery period are due to noncompliance,5 so one of the essential areas that should be evaluated prior to transplant is the patient’s ability to take medications as prescribed and to follow up with physicians as recommended.
Asking the patient, “Are you going to take medications after transplant?” often leads to unhelpful answers. A careful review of their medically related behavior history is often more revealing. Multiple missed appointments, documented noncompliance with medically recommended interventions (even for conditions other than that related to the transplant), and inconsistent attendance at hemodialysis all point to potential problems with compliance; indeed, there is evidence to suggest that pre-transplant medication noncompliance may be the only consistent predictor of posttransplant noncompliance.2
Education about the importance of treatment adherence and explicit acknowledgment of the challenges of posttransplant life, including the need to follow complex medication regimens and to stay in frequent contact with physicians, can sometimes help patients to adjust their behavior.
Another key area to assess in potential transplant candidates is their social support. Patients require extensive assistance with all aspects of their lives after transplant, and without close support they often suffer. After recovery, patients need to return to the transplant center often and, thus, require transportation. Basic needs, such as preparing food and obtaining medications, are difficult for a person to meet when recovering, therefore support is essential. It appears that living with another person is the single most protective factor for patients; being married may predict better survival.6
During the assessment period, patients should describe their posttransplant plan of care. The team should also meet the proposed support people to assess their understanding of the process and their commitment to the patient’s care.
Finally, the patient’s ability to consent to the procedure should be part of the evaluation. Knowledge of the procedure and expectations should be assessed and then tested against reality. Patients should be aware of the basic facts of transplant, including that they are to receive an organ either because someone dies or because someone has donated an organ in order for them to receive the transplant. They also should be aware of the importance and implications of immunosuppression in the postoperative period.
Knowledge of some of the facts of survival, such as the rates of peri-operative death, which patients usually exaggerate, and 1-year survival, which they sometimes overestimate, should be tested and, if inadequate, remediated with appropriate education. It should be kept in mind that, before transplant, patients often have a poor understanding of what posttransplant life will be like. This limits their ability to give optimally informed consent. Information about the nature and benefit of proposed medications along with their risks and side effects, longer-term risks associated with transplant, the need for long-term follow-up (which may include invasive procedures repeated on a fairly regular basis), and the need for frequent contact with physicians can be conveyed by the clinician.
Sometimes, past recipients of transplants are better at conveying the realities of posttransplant life to candidates and meetings should be encouraged, but there is always the risk that the team will select only the most successful recipients as ambassadors and thus skew the patient’s expectations toward the best outcomes.
Setting expectations to a reasonable level, therefore, is advisable prior to transplant. Patients should be aware that long hospital stays, extensive rehabilitation, and an extended period of disability are possible after transplant. Sometimes, patients expect to be in and out of the hospital and back to their old lives in a few weeks and, while that does occur at times, complications and setbacks are common. This knowledge is essential to providing informed consent and may help patients to cope psychologically with the vicissitudes of the posttransplant period.
Transplant Assessment Tools
Since the early days of transplant, efforts have been made to standardize the assessment of pre-transplant patients. Standardization carries great appeal for a number of reasons. Highly trained mental health professionals may not always be available to do assessments, so a self-guided assessment tool can be used by less-expert evaluators and provide valuable information. Programs at different institutions may be able to compare directly their candidates or quickly share information about patients that may be transferring from one institution to another. Standardization also promotes fairness in allocation since (at least in theory) different programs can use similar criteria.
In addition to standardization, assessment tools also allow patients to be sorted into those who need a more comprehensive assessment, and those who can proceed straight to listing.
Although there have been a number of assessment tools used to evaluate candidates, including the Psychosocial Assessment of Candidates for Transplant (PACT)7 and the Transplant Evaluation Rating Scale (TERS),8 the most recent of these, the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT), deserves some mention.9
Candidates are assessed in four domains and a total score between zero and 100 is generated. If the score is low, patients are recommended for listing as soon as the rest of their evaluation is complete. If the score is intermediate, patients receive some type of psychosocial intervention to improve their candidacy prior to listing. Finally, if their scores are high (greater than 70), they are thought to be too high risk to be successful recipients and are not considered further until they make significant changes.
The developers of this tool believe that the numerical value can be learned by other members of the transplant team quickly and can allow for a quick understanding of a patient’s situation.
Communication of Findings
A psychiatric assessment that clearly states the findings of the exam and the psychiatric recommendations for the patient (see Table 2) should be provided to the rest of the team. One advantage of including the use of a tool such as the SIPAT is that it clearly and quickly communicates the findings of the assessment to the rest of the team in the form of the numerical score.
Table 2. Elements of a Transplant Evaluation
In addition to the written report, personal communication at the multidisciplinary transplant meeting is highly desirable to ensure that the team is well-informed about the candidate. Developing strong relations with the others on the team can make it easier to provide patients with appropriate treatment prior to transplant and maximize their success. Regular attendance and participation in the team meetings can improve the team’s trust in the evaluations and their likelihood of following recommendations about management.
Management of Issues during the Pretransplant Period
One of the challenges of transplant work is that the psychiatrist is expected to provide an objective opinion about a patient’s capacity to manage a transplant and, potentially, to manage the psychiatric disorders of that same patient. This raises the possibility of a conflict between the consultant psychiatrist’s responsibility to provide objective recommendations and the treatment responsibility to advocate for one’s patient’s best medical interests. One way to circumvent this dilemma is to refer the patient elsewhere for treatment. If patients have established mental health care providers, they should be informed of the treatment plan and invited to help implement it.
However, some treatment may be provided by the transplant psychiatrist, especially if the patient feels comfortable with the situation. Patients with adherence problems can receive additional education about the importance of adherence and clear expectations about what they have to do. If they are able to meet expectations, their candidacy can move forward; if not, they should know that they will not be listed.
Another area that can be shored up during the pre-transplant period is emotional support. Getting family involved and having group meetings can improve a patient’s candidacy significantly. Sometimes, patients will report that their family is unavailable and paint a picture consistent with poor social support that turns out to be inaccurate once family do become involved.
All of these interventions require time and effort on the part of the transplant team and are not always fruitful — but when they are successful may prove decisive for being listed for transplant.
Medication for Comorbid Psychiatric Disorders
Management of psychiatric disorders during the pre-transplant period is also important. Psychopharmacology in the setting of organ failure must be done with caution, but there are almost always workable strategies. For example, in patients with end-stage renal disease or liver failure, dosing of antidepressants should proceed cautiously. Patients should start half of the recommended starting dose and be monitored closely for side effects.
Medications with significant hepatic effects, such as valproic acid or duloxetine, should be used with extreme caution in liver transplant candidates. Likewise, medications that are renally cleared, such as lithium, should either be avoided or managed by experts in the setting of end-stage renal disease.
Ultimately, patients may be able to tolerate typical doses of medications but the titration should be slow and the monitoring close. Other forms of treatment, such as psychotherapy, should also be used. Psychotherapy is much less likely to affect the patient’s physical health than medications and can give the therapist great insight into the patient. One problem, however, can be the difficulty patients have with regular attendance. Patients on hemodialysis already spend 3 half-days a week at medical appointments and often do not feel up to therapy after their session ends. End-stage liver disease commonly leads to hepatic encephalopathy and, thus, can leave patients too cognitively impaired to benefit from therapy.
In addition, since patients often travel long distances to the transplant center, weekly visits in person can be a financial and logistical challenge. These factors should all be considered before recommending psychotherapy and, if the distance is the main issue, a treatment provider closer to home may be more effective.
Substance Use Disorders
Patients with substance use disorders also require management prior to transplant. Those who are psychiatrically stable should be encouraged to enter into regular treatment (including formal treatment programs as appropriate) while they accumulate the time necessary to be eligible for listing; obviously, particularly for those early in recovery, the goal of treating patients should be to improve their insight into their substance use and the role it may have played in their illness.
During this time, patients should also be monitored intermittently for recurrent substance use with random urine drug screens; if relapse is detected, the patient’s clock starts again and treatment continues.
Unlike other addiction treatment settings, patients need to demonstrate absolute abstinence to be a candidate for transplant; harm reduction treatment models are not acceptable to transplant groups. Because of this, 12-step programs provide good treatment models for transplant patients and should be strongly encouraged as either the primary treatment or as an adjunct to individual work with an addictions specialist.
Bariatric Surgery Assessment
Bariatric surgery has become a leading treatment for obesity in the US. In 2008, it is estimated that there were about 220,000 bariatric operations performed in the US, a 13-fold increase since 1992.10 Bariatric surgery has been shown to help patients lose, on average, up to 70% of excess body weight, depending on the type of surgery performed. The procedure also decreases rates of diabetes, sleep apnea, and other obesity-related complications. Most patients who receive bariatric surgery have body mass indexes (BMI) greater than 40 and are, thus, defined as morbidly obese; patients with significantly higher BMIs are not unusual in clinical practice.
Psychological assessment of candidates prior to surgery is recommended by the major national organizations involved with the field, including the American Society for Metabolic and Bariatric Surgery. As with the transplant evaluation, evaluation of the patient’s social support is necessary, as is an assessment of their knowledge about the procedure and capacity to consent. Assessment of depression is particularly important, given that preoperative depression predicts less weight loss in the postoperative period.11
There are some other aspects of bariatric surgery, though, that also should be assessed. These include special aspects of adherence related to weight and an assessment for eating disorders either past or currently active.
Another similarity to the transplant evaluation is an assessment of likelihood of treatment compliance. As a proxy for this, many programs require patients to demonstrate the ability to lose weight on their own prior to surgery, the theory being that if patients can lose some of their excess weight, it shows that they can follow a diet, which in turn may improve their chances of following the unusual postoperative regimen necessary in bariatric surgery.
However, it should be kept in mind that patients who would likely benefit from bariatric surgery usually have been unsuccessful with any number of behavioral interventions designed to help them lose weight, including special diets and support groups. There is, therefore, a risk that they may view the surgery as a panacea that requires no additional effort on their part – but the postoperative period is in fact a time when they must continue to participate in their care. Patients have to eat small portions and for some of the procedures they cannot eat and drink at the same time due to size restrictions. Immediately after the surgery they have to follow a liquid diet for a few weeks and then usually a pureed diet after. Patients should be prepared for this and be able to discuss what the expectations are during the assessment or else they may be surprised in the postoperative period.
Comorbid Psychiatric Conditions
Morbid obesity is related to excessive food intake and, for some patients, this behavior may represent binge eating disorder (BED). BED has been proposed as a stand-alone diagnosis in the forthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5), scheduled to be published in 2013.12 The core features of the disorder include eating large amounts, some sense of shame or disgust when eating, or a lack of hunger while eating, and distress about the behavior. Unlike patients with bulimia nervosa, BED patients do not engage in compensatory behaviors and, thus, are at risk of gaining significant weight. The preoperative evaluation should therefore include assessment of BED and a discussion (if relevant) about alternative coping strategies that the patient will be able to use after surgery.
If consumption of food has been a primary way in which patients cope with emotion, they may find the postoperative period, when they cannot eat for a time and can only eat small amounts of certain food afterwards, emotionally challenging. Patients that engage in emotional eating or night eating should prepare before the surgery for the postoperative realities and work on developing positive coping strategies during the preoperative period. Patients who respond to psychotherapy for binge eating appear to lose more weight than those who do not, and it may be because they develop alternative coping strategies that they utilize after surgery.13
Patients who seek bariatric surgery may have comorbid substance abuse problems. Screening for past use of nicotine, alcohol, and both illicit and prescription drugs should be done during the pre-surgical assessment, and prior to the surgery patients should receive treatment if their use has become problematic. Indeed, some programs require patients to stop smoking prior to surgery.
There is also concern about patients starting significant substance use after surgery as a way to adjust to stress in the postoperative period. One risk marker for this is a family history of substance abuse or dependence, particularly in first-degree relatives. Patients should be warned about the risk of increased substance use prior to surgery and encouraged to get assistance if they feel their use is becoming unmanageable.14
Psychiatric assessment of candidates for organ transplantation or bariatric surgery has become a routine part of the process. These assessments are meant to identify patients at risk for poor outcomes and provide guidelines for their management. While there is little evidence to date to suggest that these evaluations improve outcomes per se, anecdotally at least, programs may find that when they disregard the findings their outcomes worsen, presumably by operating on patients with underappreciated psychosocial and psychiatric difficulties.
Intuitively, it would seem that posttransplant quality of life can be significantly improved by maximizing treatment adherence, by effectively treating symptoms of psychiatric illness (depressive and anxiety disorders in particular), and by minimizing relapse in those with a history of addiction. However, much remains to be learned about the specific psychological and psychiatric factors that impact the posttransplant course for a patient, either positively or negatively.
While it is known that anxiety and depression adversely affect treatment adherence in chronic medical conditions overall15 and there is evidence suggesting that depressive symptomatology is associated with worse outcome posttransplant,16 there has been little systematic investigation of risk factors other than prior depression, and even less of treatment response in this population — or to what extent (if at all) adequate relief of symptoms can improve adherence.
Similarly, it appears that relative to the costs associated with transplant, little attention has been paid to monitoring and specific treatment for addictive illnesses, either incident or recurrent, in the posttransplant population. Until more studies are undertaken to address these and related questions, the consultant clinician must perforce rely on extrapolation from studies of groups without the significant medical illnesses associated with need for transplant.
- United Network for Organ Sharing. Available at: www.unos.org. Accessed Jan. 21, 2013.
- Dobbels F, Vanhaecke J, Dupont L, et al. Pretransplant predictors of posttransplant adherence and clinical outcome: an evidence base for pretransplant psychosocial screening. Transplantation. 2009;87(10):1497–1504. doi:10.1097/TP.0b013e3181a440ae [CrossRef]
- Kroeker KI, Bain VG, Shaw-Stiffel T, Fong TL, Yoshida EM. Adult liver transplant survey: policies towards eligibility criteria in Canada and the United States 2007. Liv Int. 2008;28(9):1250–1255. doi:10.1111/j.1478-3231.2008.01807.x [CrossRef]
- Karim Z, Intaraprasong P, Scudamore CH, et al. Predictors of relapse to significant alcohol drinking after liver transplantation. Can J Gastroenterol. 2010;24(4):245–250.
- Dew MA, Kormos RL, Roth LH, Murali S, DiMartini A, Griffith BP. Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation. J Heart Lung Transplant. 1999;18(6):549–562. doi:10.1016/S1053-2498(98)00044-8 [CrossRef]
- Tam V, Arnaoutakis GJ, George TJ, et al. Marital status improves survival after orthotopic heart transplantation. J Heart Lung Transplant. 2011;30(12):1389–1394. doi:10.1016/j.healun.2011.07.020 [CrossRef]
- Olbrisch ME, Levenson JL, Hamer R. The PACT: a rating scale for the study of clinical decision making in psychosocial screening of organ transplant candidates. Clin Transplant. 1989;3(3):164–169.
- Twillman RK, Manetto C, Wellisch DK, Wolcott DL. The transplant evaluation rating scale: a revision of the psychosocial levels system for evaluating organ transplant candidates. Psychosomatics. 1993;34(2):144–153. doi:10.1016/S0033-3182(93)71905-2 [CrossRef]
- Maldonado JR, Dubois HC, David EE, et al. The Stanford integrated psychosocial assessment for transplantation (SIPAT): a new tool for the psychosocial evaluation of pre-transplant candidates. Psychosomatics. 2012;53(2):123–132. doi:10.1016/j.psym.2011.12.012 [CrossRef]
- Dumon KR, Murayama KM. Bariatric surgery outcomes. Surg Clin North Am. 2011;91(6):1313–1338. doi:10.1016/j.suc.2011.08.014 [CrossRef]
- De Zwaan M, Enderle J, Wagner S, et al. Anxiety and depression in bariatric surgery patients: a prospective, follow-up study using structured clinical interviews. J Affect Disord. 2011;133(1–2):61–68. doi:10.1016/j.jad.2011.03.025 [CrossRef]
- Proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders. Available at: www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=372. Accessed: Jan. 21, 2013.
- Ashton K, Heinberg L, Windover A, Merrell J. Positive response to binge eating intervention enhances postoperative weight loss. Surg Obes Relat Dis. 2011;7(3):315–320. doi:10.1016/j.soard.2010.12.005 [CrossRef]
- King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307(23):2516–2525.
- DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment. Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160(14):2101–2107. doi:10.1001/archinte.160.14.2101 [CrossRef]
- Cukor D, Rosenthal DS, Jindal RM, Brown CD, Kimmel PL. Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int. 2009;75(11):1223–1229. doi:10.1038/ki.2009.51 [CrossRef]
Transplants in the United States in 2011
||Number of Transplants
Elements of a Transplant Evaluation
||Current status, past diagnoses, past treatment, suicide attempts.
||Duration of use, severity of use, details of abuse/dependence criteria, rehabilitation.
||Patient’s self-report, attendance at appointments, review of medical record.
||Close relationships, patient’s belief about support system, plan for posttransplant.
||Understanding of procedure and postoperative course, knowledge of expected outcomes.