Transcript Psychiatric Aspects of Cardiac Transplantation Curley L. Bonds, MD

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
Overview
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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
Scope of Solid Organ Transplantation
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Kidney
Kidney/Pancreas
Liver
Heart
Lung
Small Bowel
Special Senses (Cornea, Cochlea, etc.)
Limbs (Face, Hand)
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)
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
The Transplant Team
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Transplant Surgeon
Internists & Sub-specialists
Psychiatrist/Psychologist
Transplant Coordinators/Nurses
Social Worker
Ethicists/Pastoral Services
Community Members
Pre-Transplant Evaluation
• Psychosocial Assessment
– Past Psychiatric History
– Current psychiatric symptoms/illness
– Psychotropic use
– Substance use history
– Social support
– Cognitive evaluation
– Understanding & Knowledge
Determining Transplant Candidacy
Assessment
Biopsychosocial Screening
Compliance
Social Supports
Suitability for
Transplant
Understanding &
Knowledge
Recipient’s
History and Habits
The Transplant Patient
Biological, psychiatric and ethical issues in
organ transplantation
Ed. By Paula Trzepacz & Andrea DiMartini
© Cambridge University Press 200
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 patient’s ability to
maintain abstinence
• Help the team get to know the patient
as a person to provide better care
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
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
Psychological evolution and
assessment in patients undergoing
OHT
Triffaux, Wauthy, Bertrand et al.
European Psychiatry 2001: 16: 180-5
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
Measures Employed
• Speilberger’s State-Trait Anxiety
Inventory
• Beck Depression Inventory
• Perceived Social Support Scale
• Toronto Alexithymia Scale
• Personal Reaction Inventory
Pre-operative pathology
• 41% (n=9) of patients had some DSM
IV Axis I Diagnosis
• 18% (n=4) presented with an Axis II
condition
Psychosocial Risk Factors for Noncompliance
• History of substance abuse
• Age <30
• Experiencing economic or psychosocial stress
Surman 1992
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
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)
Prognostic Factors for Substance Dependence
and Abuse Recidivism
POSITIVE FACTORS
NEGATIVE FACTORS
• Stable living environment
• Resources for abstinence
• Recognition and acceptance
of dependence as a problem
• Absence of concurrent
psychiatric disorders
• Compliance with posttransplant recommendations
for addictions care
• Preexisting psychotic
disorder
• Unstable character disorder
• Unremitting polydrug abuse
• Multiple failed attempts at
rehab
• Social isolation
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
Psychotic Disorders as a Contraindication to OHT
at US Transplant Programs
Absolute
Contraindication
Relative
Contraindication
Active
Schizophrenia
92.3%
5.1%
2.6%
Controlled
Schizophrenia
33.3%
51.3%
15.4%
Irrelevant
Levinson & Olbrisch, 2000
Affective Disorders as a Contraindication to OHT at
US Transplant Centers
Absolute
Contraindication
Relative
Contraindication
Irrelevant
Current
Affective
Disorder
44.9%
47.4%
7.7%
Hx of
Affective
Disorder
5.1%
62.8%
32.1%
Levinson & Olbrisch, 2000
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 SI
75.6%
17.9%
6.4%
Mental Retardation/IQ as a Contraindication to
OHT at US Transplant Centers
Absolute
Relative
Contraindication Contraindication Irrelevant
MR
IQ >70
25.6%
59.0%
15.4%
MR
IQ <70
74.4%
19.2%
6.4%
Levinson & Olbrisch, 2000
Dementia as a Contraindication to OHT at
US Transplant Centers
• Absolute contraindication: 71.8%
• Relative contraindication: 23.1%
• Irrelevant: 5.1%
Levinson & Olbrisch, 2000
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
Assessment Tools
• TERS - Transplant Evaluation Rating
Scale
• PACT – Psychosocial Assessment of
Candidates for Transplantation
Predictive Value of Pre-Op Assessment
Psychiatric Disorders and Outcome
Following Cardiac Transplantation
Skotzko, et al., J. of Heart and Lung
Transplantation, 1999
Predictive Value of Pre-Op Assessment
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107 OHT recipients
Transplanted Jan. ’90 - Sept. ’91
Retrospective chart review
Medical outcomes measured:
1 year survival
rehospitalizations
infections
rejections
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
Pre-Operative Issues
Waiting
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
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
Pre-Operative Interventions
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Transplant Support Group
Internet/Online Support Groups
National Heart Association
Transplant Olympics
Individual Psychotherapy
Antidepressants/Anxiolytics
Post-Operative Issues
Rehabilitation
1st Three Years after OHT
• 191 OHT recipients were followed for 3
years:
– Major Depressive Disorder
– Adjustment Disorders
– PTSD-T
– Any Disorder
Dew, Kormos, et al Psychosomatics2000
25.5%
20.8%
17%
38%
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.”
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
UCLA Experience
Subjects with Axis I Disorders vs Subjects with No Psychiatric Disorders*
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44
45
40
35
29
Percentage
30
24
25
Subjects with Axis I Disorders
(N=21)
24
19
20
19
19
20
Subjects with No Psychiatric
Disorders (N=31)
15
10
5
3
2
0
*p values insignificant
Mortality
1 Year Rejection
1 Year Infection
2 Year Infection
Readmissions
UCLA Alternate Transplant List
Subjects >65, Axis I Disorders vs No Psychiatric Disorders*
90
83
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80
70
67
67
67
Percentage
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50
50
Subjects >65 with Axis I Disorders
(N=3)
Subjects >65 with No Psychiatric
Disorders (N=6)
40
33
33
30
20
10
0
0
0
Mortality
1 Year Rejection
1 Year Infection
2 Year Infection
Readmissions
*p values insignificant
UCLA Experience: Axis II Pathology
Subjects with Axis II Disorders vs Subjects with No Psychiatric Disorders*
80
70
67
67
60
Percentage
50
44
Subjects with Axis II Disorders
(N=3)
40
33
Subjects with No Psychiatric
Disorders (N=24)
29
30
24
20
20
10
3
0
0
0
Mortality
1 Year Rejection
1 Year Infection
2 Year Infection
Readmissions
*p values insignificant
Psychiatric Evaluations of Heart
Transplant Candidates: Predicting
Post-Transplant Hospitalizations,
Rejection Episodes, and Survival
Owen, Bonds, Wellisch
Psychosomatics 2006: 47:213-222
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
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 posttransplant complications
Outcome Measures
• Re-hospitalization/Rejection
• Infection
• Death
Methods
• 108 OHT recipients followed for average
of 970 days
• Transplanted between 1997 and 2000
• >18 years old
• Followed by UCLA Heart Transplant
Team
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
Risk Assessment
• Good Candidates – 50%
• High Risk- 11.1%
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
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
Predictors of High Risk Classification
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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
Demographic Predictors of Risk
• Age (younger)
• Marital status (single)
• Gender (female)
Survival as a Function of Psych Risk
Neuropsychiatric Aspects of
Immunosuppressive Agents
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Cyclosporine
Neoral (microemulsified cyclosporine)
Tacrolimus (FK506)
Cellcept (Mycophenolat mofetil)
Corticosteroids
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
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. John’s wort may decrease levels.
Tacrolimus (FK 506)
Dosage Forms: PO, IV
Serum Levels: 8-15ng/ml
Anxiety, delirium, insomnia, restlessness
Cellcept (mycohpenolat mofetil)
Dosage Forms: PO, IV
Anxiety, depression, somnolence, nausea,
vomiting
Corticosteroids
Dosage Forms: PO, IV
Delirium, euphoria, depression, mania,
insomnia, tremor, irritability, weight
gain, memory impairment
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
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
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
fin