September 28, 2016 | Comorbidity In Psychiatry By Paula Zimbrean, MD, Catherine Crone, MD, Yelizaveta Sher, MD, Mary Amanda Dew, PhD, and Andrea DiMartini, MD Academy of Psychosomatic Medicine (APM), Transplant Psychiatry Special Interest GroupOrgan transplantation is the accepted treatment for many patients with chronic or acute advanced organ disease and certain types of cancer. Currently, there are over 120,000 patients in the US waiting for solid organ transplant (nearly 100,000 are kidney transplant candidates), and the wait list continues to grow. However, because of the shortage of donated organs, only about 30,000 transplants are performed each year and 10% to 18% of candidates will not survive to transplant. Most wait a year or more for a donated organ, while many kidney candidates wait 3 to 5 years.
Most organ transplant programs recognize the need for a multidisciplinary team to assist with the complexities of transplant patient care. Moreover, the United Network for Organ Sharing recognizes that “mental health and social support services are essential for the total care of transplant recipients, living donors and their families” and thus requires the availability of such services by trained individuals.1 Historically, psychiatrists and mental health professionals contributed primarily during the pretransplant evaluation phase, assisting transplant teams in determining the suitability of candidates for transplant and preparing candidates for the procedure.
Over the past 3 decades, the increasing numbers of candidates and recipients as well as the expansion of organ transplantation to more than 500 programs in the US have both increased the demand for mental health services within transplant programs and fostered the development of a specialized area of transplant psychiatry. Psychiatrists are increasingly considered integral members of the transplant team and are often embedded within the transplant units and clinics to provide continuity of psychiatric care.
The limited organ availability; extensive health care resources required; and degree of personal responsibility, self-management, and strict adherence to transplant directives needed of transplant recipients for successful outcomes necessitate careful candidate selection. Psychiatrists evaluate the extent to which psychiatric, psychological, and behavioral disorders may contribute to poorer outcomes and assist in designing treatment plans to ameliorate identified risks.
Following transplant, psychiatrists may be consulted on psychiatric or behavioral issues as they arise during the recovery period. Innovative strategies for dealing with these complex patients have been developed, including the adaptation of common therapeutic strategies specifically for transplant-related scenarios.
Phases of transplant
Organ transplant is not a singular surgical event but a series of transitions between specific phases beginning with the diagnosis of advanced organ disease. From referral to the transplant team to long-term adaptation to life as a transplant recipient, each phase is associated with different stressors that require different skills and resources from patients, their family and friend caregivers, and the mental health clinicians who care for them. The Figureillustrates the potential medical and psychosocial stresses inherent in each phase for patients and their caregivers.
The pre-transplant phase is commonly associated with anxiety over being evaluated and accepted onto the transplant wait list. Many patients and their families initially experience elation and relief over being listed but then find the uncertainty of waiting for an organ to be the most psychologically stressful part of the transplant experience. Those who have been chronically ill may look forward to transplant with its potential to improve their quality of life, while those who became acutely ill may view transplant with apprehension. Patients can experience a slow decompensation or rapid progression from acute exacerbations. Wait-list patients can experience medical events (eg, infection, stroke, myocardial infarction) that may make them ineligible for transplant.