Transcript Psychiatric & Psychological Treatment Issues in

Psychiatric & Psychological
Aspects of Transplantation
Dr Cathy Walsh
Consultant Liaison Psychiatrist
Cambridge & Peterborough NHS Foundation Trust
Addenbrooke’s Hospital, Cambridge
+ Papworth Hospital, Cambridgeshire
Overview
• Why do transplant services need psychiatrists?
• Background
– Transplantation
– Considerations in organ allocation
• The transplant journey – what we manage & treat
• Psychological aspects of transplantation
• Psychiatric aspects of transplantation
• Pre-transplant assessment
Why do Transplant Services need us?
• Transplantation is not a one-off surgical event
but an ongoing process which carries unique
psychological challenges.
• Transplant candidates usually have a
background of chronic physical illness which
greatly increases their risk of psychological
and psychiatric morbidity
• End stage organ failure may be mediated
through abnormal behaviours (eg.
alcohol/drug abuse, paracetamol overdose,
abnormal eating behaviour, poor compliance)
Why do Transplant Services need us?
• There are frequent misconceptions among
transplant teams about the nature &
treatability of mental illness.
• Appropriate psychiatric or psychological
intervention can significantly improve a
patient’s candidacy for transplantation.
• Appropriate psychiatric or psychological
intervention can improve physical health
outcomes, including graft survival
Solid Organ Transplantation
•Heart
•Lung
•Liver
•Kidneys
•Pancreas
•Small bowel
Survival following transplantation
1 year
5 years
10 years
Kidney
97%
93%
68%
Liver
90%
76%
60%
Heart
81%
71%
55%
Lung
77%
54%
25%
Improvement in survival
•
•
•
•
•
Tissue typing
Organ preservation
Immunosuppressant drugs
Surgical techniques
Use of heart beating and
live donors
Donor organs
• Non-heart beating donor (NHBD)
• Heart beating donor (HBD) – organs are
harvested from only 10-20% of potential
donors. Family & cultural issues.
• Live donor (LD)
Number of deceased donors and transplants in the UK, 1 April 2001 - 31 March 2011,
and patients on the active transplant lists at 31 March
8000
7877
7997
7800
7655
7000
7219
6698
6000
6142
5604
5654
5673
Number
5000
Donors
Transplants
Transplant list
4000
3000
2247
2388
2396
2241
2196
2385
2381
2552
2645
2695
2000
1000
745
777
770
751
764
793
809
899
959
1010
0
2001-2002
2002-2003
2003-2004
2004-2005
2005-2006 2006-2007
Year
2007-2008
Source: Transplant activity in the UK, 2010-2011, NHS Blood and Transplant
2008-2009
2009-2010
2010-2011
WHO SHOULD GET A TRANSPLANT?
Organ AllocationGuiding Principles?
• Treating people equally
– Waiting list
• Greatest need
– ‘Rule of rescue’  “Our moral response to the
imminence of death demands that we rescue the
doomed”.
• Greatest benefit
– Maximising total benefits Life years gained
• Promoting and rewarding social usefulness
WHAT ABOUT DISEASE WHICH IS
PERCEIVED AS ‘SELF-INFLICTED’?
What about people with
mental illness?
Impact of Equality
Act 2010?
Potential for more
challenges in relation to
decisions regarding
medical interventions
What do the organ donors think?
What are the priorities of the public?
BMJ Jul 1998; 317: 172 - 175
Assessing priorities for allocation of donor liver grafts: survey of
public and clinicians - James Neuberger, David Adams, Paul
MacMaster, Anita Maidment, Mark Speed
•Compared priorities of the general public, family doctors and
gastroenterologists in allocating donor livers
•Presented 8 hypothetical cases and asked respondents to select 4 for
transplantation. Cases covered controversial issues eg. extremes of age,
anti-social behaviour and substance misuse
• Asked to select 4 of 7 criteria for allocation of donor organs: time on
waiting list; age; ‘value’ to society; alcohol consumption; work status; likely
outcome of transplant; drug use.
A 9 month old boy has liver disease. Without a transplant he will die in
18 months. He has three older brothers and one older sister (lower age limit)
A 21 year old woman is diagnosed with liver cancer when 8 months' pregnant.
She will die in 6 months without the transplant. If transplanted, she has only a
one in two chance of being present at her daughter's 1st birthday party but a one
in 10 chance of a cure and living for 10 or more years (emotional)
A 50 year old man is in prison serving a long sentence for grievous bodily harm.
He has a serious liver disease from which he will die in 9 months (criminal
record)
A 45 year old garage owner with a wife and two young children has drunk
heavily since he was 18. This has led to liver and kidney failure. He has
2 months to live if he is not transplanted (alcohol)
Results: Priorities of public differ from the medical profession. Public more
likely to prioritise on emotional basis and to rank those with anti-social
behaviour as lowest priority
BMJ Jul 1998; 317: 172 - 175
'You should have let my dad die'
Last updated: 28/05/2009 10:05
The family of a suicidal father-of- three who was given a liver
transplant against his wishes have criticised the NHS for
"wasting" a donor organ.
Given the controversies regarding mental
illness & transplantation - what is our role?
Pre-transplant
• Providing an expert view
regarding psychiatric &
psychological risk factors
which might jeopardise
candidacy (future compliance)
 contributing to complex
listing decisions
Post-transplant
• Optimising mental health 
managing psychological &
psychiatric morbidity 
ensuring compliance & graft
survival
• Optimising candidacy
But…. Very limited data re psychological predictors of outcome.
No
data re impact of transplant on the course of psychiatric disorder. Need
to address these gaps.
Understanding the Transplant Journey
A transplant is not a one-off surgical event
but a continuous process
THE TRANSPLANT JOURNEY
End stage organ
failure Chronic illness
Referral to
transplant centre
Declined
transplant
Assessment
(physical &
psychosocial
evaluation)
Conditional acceptance
Eg. ↓ weight, stop smoking
Good outcome
Listed for
transplant
Poor outcome
End of life
Unpredictable wait
Life long medical follow up
Appointments, blood tests, changes in
meds. Episodes of rejection, infection,
↑ cancer risk, side effects.
‘Bridging’ tx
eg dialysis, VAD,
ECMO, PN
Deterioration/death
while waiting
‘False alarms’
Post-op course, ITU stay
Start immunosuppressants
Transplant
Surgery
Psychological issues associated
with transplantation
The Psychological Journey
• Unpredictable wait for a
suitable donor + false
alarms
• Possibility of death/medical
de-compensation whilst
waiting (may become
ineligible).
• Loss of control
• Genetic disorders – guilt,
impact on family.
• Face major surgical
procedure with risk of lifethreatening complications
• Episodes of rejection, SEs
• Self-care
• Unrealistic expectations
regarding  quality of life 
post-transplant depression
• Role change – most
difficulties at 4 & 12 months
• Younger patients. Family &
developmental issues
• Preoccupation with donor
(eg. guilt, unworthiness,
identification).
• Ambivalence re transplant
Vignette- Coping with loss
• 46 year old woman
• Dilated cardiomyopathy  VF arrest x 2  ICD  ↑ heart
failure  transplant referral
• High HLA antibody titre  VAD as ‘bridge’. Listed for
transplant but unlikely to get match
• Referred  low mood/anxiety
• Context  3 children. Lost her own mother age 8 –cardiac
causes. Husband high functioning but past psychiatric
problems. Always the ‘lynchpin’ of the family.
• Issues: uncertainty re transplant, curtailed life span, genetic
testing, fears for children, marital issues, “loss of faith”.
Anxiety  over-attending to physical sensations 
misinterpreting as evidence of VAD dysfunction
Younger patients have additional challengesWhat are we doing about transition services?
Graduating from paediatric to adult services
• Impact of chronic illness & transplantation on development
– physical, intellectual, psychological (& personality), social
• Educational issues
• Family dynamics
• Relationships & fertility issues
• Often body image disturbance
• Life expectancy
Vignette - The legacy of childhood illness
26 year old man. Intestinal failure secondary to inflammatory bowel
disease. Problems since early childhood. Liver cirrhosis secondary
to PN & increasing problems with vascular access. Referred as
non-compliant with investigations, difficult relationship with staff, GI
team believe transplant is only option to extend life….
“I was quite understandably depressed for a long time - I felt that there was no way out of
my situation. My doctors were positive that a multi-visceral transplant would offer the best
chance but I was uncertain. I had been through 20 years of medical procedures designed to
improve my ‘quality of life’ and, while some had worked for a while, it was always the case
that at some point in the future I’d end up back at square one. Along with that experience
was the thought that if I just let things continue to deteriorate, I’d finally be free of my
somewhat unhappy life when I died….”
“It was at this point that I agreed to go to counselling. Over time I developed the clarity to
commit to a choice and to stick with it..”
“ It’s one week since I’ve been released from hospital. I’m sitting at my computer looking thro’ the kitchen door where I
can see empty spaces. Empty spaces where for many years stood a drip stand, folding metal table, mobile drip stand,
mobile pump, fridge, a box of saline & various ancillaries such as sterilizing sprays, alcohol wipes, syringes, saline
flushes, sterile gloves and & dressing towels. I mention them because they are a symbol of the life that was mine for
many years, reliant on a specially prepared bag of nutrients to be administered using aseptic techniques to provide my
fluid intake and nutrition. A solution had to be stored at the right temperature, protected from light & then infused via
my specially inserted central line for most of the night & early morning. To say it was intrusive would be an
understatement, but it was a necessity. A necessity because I had no working bowel left - it was also a necessity that was
slowly killing my liver. So the transplant of bowel and liver has allowed me to leave that lifestyle behind …….. ”
“ It’s easy to remember all the physical symptoms that have been ‘lost’ with transplantation - the severe nose bleeds, the
high stoma output & always needing to be near a toilet, disruption of sleep .. . But there are mental ‘losses’ too. The
feelings of hopelessness that my life had become reduced to mere existence ………the feeling that I was a prisoner to my
illness. I’m pretty sure I made the right choice in the end … leaving hospital after eating a meal that I digested perfectly
was a miracle ... It’s all still quite new but one change I can definitely see is that I feel much more positive about the
future &, for the first time in years, I actually feel that I’m ‘normal’.”
PSYCHIATRIC PROBLEMS
ASSOCIATED WITH
TRANSPLANTATION
What about psychiatric illness?
• Transplant candidates frequently have a high loading
for psychiatric morbidity:
– Long term conditions
– Organ failure arising from maladaptive behaviour
(alcohol, drugs, paracetamol OD, poor self-care
secondary to depression)
– Iatrogenic factors eg. opiate dependence
• Co-incidental comorbid psychiatric illness
• Transplantation can act as a precipitating factor
– Stress of transplantation  de novo illness or
interaction with existing vulnerability
– Organic factors eg. Steroid-induced psychosis
Psychiatric problems
associated with transplantation
• Can manifest pre-, peri- or post-transplantation
• Common – depression, anxiety & adjustment disorders
• Less common – psychosis/mania, PTSD, return to
substance misuse , personality difficulties
• Personality disorder – pre-existing difficulties
exacerbated by the stress of transplantation leading to
maladaptive behaviour (eg. non-compliance, poor
relationship with staff)
• Organic brain syndromes (delirium, organic psychosis,
neuropsychiatric syndromes related to
immunosuppressants)
Organic Brain Syndromes
- delirium, organic psychosis, other neuropsychiatric
presentations
• Cerebral consequences of
chronic organ failure
• Residua of anaesthesia &
lengthy surgery
• Volume/electrolyte shifts 20
reperfusion of new organ
• Cyclosporine loading,
steroids + other med SEs
• Opiate treatment
• Early graft dysfunction
• Infection & other processes
• Pre-operative cognitive
impairment related to
underlying disease processes
(eg. hepatic encephalopathy)
usually  substantial
improvement post-transplant
but may be hard to
differentiate pre-transplant
what is likely to be reversible
• Cognitive symptoms 20
immunosuppressant meds
generally immediately post-op
when dosing high
Immunosuppressant Drugs
Corticosteroids (tapered early) - prednisolone
Antiproliferative immunosuppressants (inhibit
DNA synthesis)- azathioprine, mycophenolate
Calcineurin inhibitors - cyclosporin, tacrolimus
Transplant patients are usually maintained on
a corticosteroid combined with a calcineurin
inhibitor or antiproliferative agent, or with
both.
Vignette – Refusal of treatment
• 50 year old married man, hepatitis C cirrhosis
• Past history IVDU. Stable on methadone X 25 years.
• No other  problems. Stable employment history & stable
family life > 20 years.
• Chronic encephalopathy. Methadone stopped in DGH.
• Pre-transplant  assessment limited by encephalopathy.
• Transplant but very difficult post-operative course  blood
loss, reperfusion injury  back to theatre x 2. ITU.
• Stabilised but ↑ withdrawn & uncommunicative. Started to
refuse treatment. Also refusing  assessment.
• Graft rejection
•  assessment  depressed with psychotic features. Belief
that staff trying to kill him as a ‘punishment’  palming
medication
• Management:
– Section 2 MHA
– citalopram & haloperidol via NGT
– Medical treatment under Common Law (pre-MCA) 
stop steroids + switched immunosuppressant.
Medication via NGT
– Section 62  ECT x 4 (1st treatment 2 weeks posttransplant)
• Highlights:
–
–
–
–
–
–
–
pre-existing risk factors
relevance of methadone withdrawal?
limitations of pre-transplant  assessment
contribution of organic factors
urgency arising from graft failure
mental capacity issues
safety of ECT post-transplantation (at least in this case)
Vignette – the unresponsive patient
•
•
•
•
50 year old man. Recurrent depression.
Paracetamol overdose  fulminant liver failure
Encephalopathy  limited assessment
Transplant  ITU. Awake but unresponsive. No
focal neurology.
•  Referral  “he’s catatonic”
• Assessment - organic brain syndrome
• Brain MRI ………..
18/07/07
7/8/07
15/9/07
Immunosuppressant-induced leukoencephalopathy or
‘Posterior Reversible Encephalopathy Syndrome’
• PRES  seen in organ transplantation; pre- & eclampsia;
allogenic bone marrow transplantation; autoimmune disease;
high dose chemotherapy.
• Tacrolimus & cyclosporin both implicated
• CT/MRI  widespread oedema. Parietal & occipital lobes most
commonly affected - hence ‘posterior’.
• Mechanism unclear - Oedema related to hypo- or hyperperfusion?
• Clinical features variable but can include altered mental state,
headache, visual disturbances, nausea, paresis, seizures.
•
REVERSIBLE
What is the purpose of
pre- transplant psychiatric
assessment?
Pre-transplant psychiatric assessment
• Is this patient likely to develop psychiatric
difficulties which might affect their
compliance or jeopardise graft survival?
• What, if anything, can be done to eradicate,
minimise or manage this risk?
• Will these measures be sufficient to justify
listing the patient for transplantation?
• Do they understand what is entailed? Are they
motivated and psychologically prepared?
Psychiatric assessment of
potential transplant recipients
• Past psychiatric history
• Drug/alcohol history
• Current psychiatric
symptoms
• Family psychiatric history
• Personal background
• Social circumstances &
adequacy of support
system
• Personality & coping style
• Mental state examination
• Cognitive assessment
• Medical history/context of
transplant assessment
• Compliance issues
• Attitude to transplant,
understanding and
emotional preparedness
• Decision making capacity
• Pharmacological issues : 1)
organ failure; 2) potential
interactions btw
psychotropic &
immunosuppressant meds;
3) pain management
What about alcohol?
• Patients tend to be highly selected &
abstinent x 6/12
• But … At least 10% return to drinking
> 21 units - 5% grafts lost
• Little data re predictors of recidivism
• Action without contemplation?
• Should we be doing these
assessments differently with
motivation interviewing focus?
• As alcohol dependence is a relapsing/
& remitting disorder should relapse
prevention be always available?
Benefit of pre-transplant
psychiatric assessment?
• Rare to advise against transplant
– Routine assessments: patients usually highly selected
before assessment and keen to present positively.
– Urgent & emergency assessments: patients critically ill &
often acutely confused. Time-frame too short for
comprehensive evaluation.
• Limited data relating to psychological/psychiatric
predictors of outcome. Few data relating to impact of
transplant on course of psychiatric disorder.
• Greatest value might be in:
– Optimising candidacy (eg. enhanced support/intervention
if appropriate)
– Contingency planning where risk factors exist