The pre-transplantation assessment

The pre-transplant assessment is done to assess the patient's suitability for transplantation (Boxes 1 & 2). The assessment consists of a clinical psychosocial assessment with a full psychiatric history and mental state examination, including cognitive function testing. The patient's attitude to transplantation is explored, along with their current complaints, their own and family psychiatric history, personal history, substance use history and personality. Validated instruments such as the Stanford Integrated Psychosocial Assessment for Transplantation may also be used. The prospective transplant recipient is assessed by the members of the multidisciplinary team. Subsequently, the team members, including the liaison psychiatrist, meet to report their findings and to decide on whether the patient should be put on the transplant list. The liaison psychiatrist is well placed to conduct the psychiatric assessment as they are based in the acute hospital and have regular contact with the relevant medical and surgical teams, along with the allied health professionals. Contact may be made with any general adult or addiction service with which the patient has had prior involvement. Such services provide useful information particularly about substance use and adherence to treatment. The patient's general practitioner may be also contacted to obtain psychosocial information.

Attitude to transplantation

In the assessment, enquiry is made about the patient's attitude to transplantation. Has the patient received sufficient information about the procedure and its aftermath? What is their knowledge and understanding of transplantation? Have they carefully considered the pros and cons of having or of not having the transplant? Do they understand the requirements for aftercare? Have they thought about the potential donor? Would they proceed if offered a transplant? This exploration also covers aspects of informed consent. Some patients are suitable surgically for transplantation, but decline the transplant for personal reasons. A proportion of patients become ambivalent after receiving transplant-related information. It is important to allow sufficient time for the patient to process the difficult and complex material. The ambivalence may not be related to educational level. With good support, patients with virtually no literacy can engage well and understand the complexities of transplant-related material. However, in my experience, when a patient is very sick physically with a reduced life expectancy and poor quality of life, they usually request a transplant. Patients know they have few options.

Current complaints

The liaison psychiatrist elicits current psychiatric symptoms, if any, along with any psychotropic use. The patient may have anxiety or depressive symptoms. In adult patients with cystic fibrosis, the prevalence of anxiety is higher whereas the prevalence of depression is lower than in the general population (Goldbeck Reference Goldbeck, Besier and Hinz2010). However, patients with end-stage lung disease other than cystic fibrosis, namely emphysema and idiopathic pulmonary fibrosis, have higher pre-transplantation anxiety scores than those with cystic fibrosis, possibly because cystic fibrosis patients have better social supports and coping strategies (Burker Reference Burker, Carels and Thompson2000). Any identified mental illness is treated – a comprehensive management plan is put in place. However, the presence of active psychotic symptoms is regarded as a relative contraindication to transplantation.

The patient's and family's psychiatric history

The patient's and the family's psychiatric history can be crucial in the decision to ‘list’ a patient for transplantation. Family history is useful in terms of raising awareness of potential risk factors.

Enquiry is made about psychiatric history, including details of diagnoses made, the severity and chronicity of illness, functional impact, treatment received and response to treatment. In particular, details of contact with mental health services, the general practitioner, previous admissions, out-patient attendances, medication prescribed and therapies undertaken are all documented. Adherence to treatment is carefully evaluated in terms of attendance at clinic appointments, medication use and engagement with psychologists or therapists. An opinion has to be formed as to the patient's ability and willingness to collaborate with the transplant team and comply with the medical regime. Furthermore, an opinion is made about the patient's ability to cope with the surgery, a major life event. Failure of treatment adherence is regarded as a relative contraindication to transplantation.

A recent suicide attempt or a history of repeated suicide attempts are generally regarded as absolute contraindications to transplantation (Levinson Reference Levinson, Olbrisch, Trepacz and DiMartini2000), whereas a remote history of a suicide attempt is a relative contraindication.

A history of self-harm is also deemed to be a relative contraindication to transplantation. Has the patient a personality disorder? Has the patient a history of impulsivity and unstable moods? Was the self-harm a suicide attempt? Was it impulsive or planned? What was the reason for the self-harm? What is the likelihood of another attempt, particularly if the patient receives a transplant? These questions need to be addressed. Clinical judgement is required. Generally, the transplant team will be reluctant to perform a transplant if the patient has a history of self-harm. The liaison psychiatrist may need to take on a patient advocate role if appropriate.

Personal history

In personal history, an assessment of functioning, ability to live independently and the level of supports available to the patient is crucial. Careful evaluation is required. Furthermore, evaluation of personality is relevant because of risk-taking, adherence issues and stability of support systems. Enquiry is made about religious beliefs and practice, as well as involvement in community-based activities.

Substance use

The substance use (alcohol and drug) history needs careful exploration. Substance use itself may be a cause of organ failure, as in cocaine-related dilated cardiomyopathy, or it may be incidental. Substance misuse is associated with poor adherence pre-transplantation and is a risk factor for non-adherence post-transplantation (Surman Reference Surman and Portillo1992). Substance dependence can lead to complications post-transplantation such as a withdrawal state that could jeopardise the success of the transplant.

Active alcohol misuse, ongoing dependence or any illicit drug use are generally regarded as contraindications to transplantation. The consensus is that a patient with alcohol or drug misuse or dependence must be abstinent from alcohol or drugs for 6 months before being listed for transplantation. Generally, the history given by the patient is sufficient in evaluating substance use. However, if there is any uncertainty or if the history does not seem to match clinical findings, then a collateral history is required. If a patient is dependent on a substance, then I insist on the patient being abstinent, attending an addiction service and providing supportive evidence from the addiction team/counsellor of abstinence prior to being listed for transplantation. The supportive evidence may include random blood or urine testing or even hair sampling.

There is debate about the clinical significance of cannabis use by candidates. Is a patient who uses cannabis in small quantities, perhaps only at weekends, suitable or unsuitable for transplantation? Clinical judgement is required on a case-by-case basis and discussion at the multidisciplinary transplant team meeting is required.

Substance misuse may be hidden. A detailed alcohol history is required for patients with ‘idiopathic’ cardiomyopathy. A high index of suspicion is required for prescribed drug misuse or dependence. Hidden opiate dependence may be present in a patient with ischaemic cardiomyopathy prescribed regular opiates for recurring chest pain. Similarly, benzodiazepine dependence may be present in an anxious patient with chronic lung disease. Undetected dependence can lead to a withdrawal state post-transplantation and complicate post-operative care and recovery.

Mental state examination

The initial assessment provides a baseline of mental state which is useful when following the patient through their illness journey. Later mental state examinations can be compared with the initial examination. Certain findings set off alarm bells. Active psychotic illness is a relative contraindication to transplantation. However, clearly there is a major difference between an acute psychosis that is likely to respond to treatment and a chronic and severe illness, with functional impairment, that may be treatment resistant.

There is no universal agreement as to whether the presence of mental illness is an absolute or relative contraindication to transplantation. Patients with illnesses such as bipolar disorder that is well controlled on lithium and who are adherent to their treatment can do very well post-transplantation. Consequently, it is the severity, chronicity and response to treatment of an illness that have to be considered.

If cognitive deficits are suspected that could impair self-care and adherence post-transplantation, specific neuropsychological testing may be required. The expertise of a neuropsychologist is needed and neuropsychological intervention may be helpful. Certain patient groups are at higher risk of specific deficits: a patient with vascular disease and ischaemic cardiomyopathy may have cognitive deficits such as those associated with a vascular dementia. Significant cognitive impairment is a relative contraindication to transplantation.

An estimation of IQ may be required if intellectual disability is present. An IQ of less than 70 is considered a relative contraindication to transplantation. However, what matters is the patient's ability to function and live independently, as well as the level of supports available to them.

Validated instruments

There are several instruments to measure pre-transplant psychosocial factors and likely treatment adherence (Box 3). The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) (Maldonado Reference Maldonado, Dubois and David2012) is a comprehensive screening tool designed to standardise the psychosocial assessment of organ transplant candidates. It encompasses 18 psychosocial risk factors covering the following four domains: the patient's readiness level and illness management; social support system; psychological stability and psychopathology; and lifestyle and effect of substance use. It is scored from 0 to 115, with higher scores indicating higher risk. It has been used in heart, lung, liver and kidney transplant candidates. Other, older tools used include the Psychosocial Assessment of Candidates for Transplantation (PACT) (Olbrisch Reference Olbrisch, Levenson and Hamer1989) and the Transplant Evaluation Rating Scale (TERS) (Twillman Reference Twillman, Manetto and Wellisch1993). The PACT has eight subscales as well as an initial and final rating. It has four domains: social support; psychological health; lifestyle factors; and understanding of transplant and follow-up. The TERS covers seven domains: substance misuse; adherence; health consciousness; social support; past coping; dealing with the current disease; affect; and mental status. I think that the clinical evaluation is enhanced by the use of an assessment tool.

With regard to personality assessment, validated instruments such as the Minnesota Multiphasic Personality Inventory (MMPI) may be used if personality disorder is suspected, particularly if adherence is an issue.

Assessment and prediction of outcome

Careful pre-transplantation assessment is important because psychosocial factors may have a significant bearing on the medical outcome post-transplantation. The prognosis for those with psychiatric disorder is worse post-transplantation. In a study by Owen et al (Reference Owen, Bonds and Wellisch2006), 108 heart transplant recipients were followed for an average of 970 days. It was hypothesised that psychiatric risk factors (e.g. recent substance misuse, history of suicide attempt, having a personality disorder, low levels of social support, poor past adherence to medical regimens) would be associated with a greater likelihood of post-transplantation complications, including re-admission to hospital, organ rejection, infection and death. The study found that increasing psychiatric risk classification was associated with a greater hazard of post-transplant mortality, but not of infection or re-admission. However, a history of suicide attempt was strongly associated with time to infection or rejection.

The detection of mental disorders pre-transplantation is also relevant to psychosocial outcome. Chacko et al (Reference Chacko, Harper and Kunit1996) found that Axis I disorders were associated with poorer psychosocial adjustment and health status, whereas Axis II diagnoses were associated with poorer adherence post-transplantation.

Scores obtained using the SIPAT have been used to predict medical and psychosocial outcomes post-transplantation. At 1-year follow up, the higher the scores on the SIPAT the greater the adverse medical and psychosocial outcomes (Maldonado Reference Maldonado, Sher and Lolak2015). Higher scores predicted higher rates of rejection episodes, medical admissions, infection rates, psychiatric decompensation and support system failure.

Bridge to transplant

One of the unique features of heart and lung transplantation is ‘bridging’. Bridging refers to a wide range of intensive care measures that try to stabilise a patient who is in an imminently life-threatening situation. One example is an extracorporeal membrane oxygenation (ECMO) system, which enables direct oxygenation of the blood or CO₂ extraction from the blood. Bridging is regarded as a short-term measure while an organ is awaited. It can be very stressful for the patient, family and staff. A patient can be ‘listed’ for transplantation but be too sick to be discharged, be on maximum medical therapy and be deteriorating physically while awaiting a transplant. Such patients may openly express their fears of dying to nursing staff, who may feel helpless and guilty about not being able to do more to save their life. Such situations are challenging. Psychological support for the patient is essential. For hospital-bound patients, online support groups, apps and other online therapies may be useful. Similarly, individual psychotherapy, antidepressants or anxiolytics/hypnotics may be required. However, with a critically ill patient, decisions about benzodiazepine use are complex, such as when to prescribe anxiolytics without causing respiratory depression in an anxious breathless patient with severe lung disease. The clinical expertise of the liaison psychiatrist is useful in determining when and what to prescribe, and the intervention can allay the fears of the treating medical team.

Drug treatment

There is a paucity of published data on the safety of psychotropic medication in transplant recipients. If medication is required, the choice of drug needs to be considered carefully. What is safe to use? What dose is appropriate? What side-effects are likely? What drug interactions might occur? How significant are the altered pharmacokinetics? Selective serotonin reuptake inhibitors (SSRIs) are suitable for major depression and panic disorder in heart and lung transplant patients. However, as many SSRIs are metabolised by the same cytochrome P450 isoenzyme system as cyclosporine, elevated cyclosporine levels can occur. Certain psychotropics, especially nefazodone and fluvoxamine, should be avoided because of their interactions with calcineurin inhibitors. Cyclosporine levels should be monitored. However, given that the patient will be on a multiplicity of medications, I think that the best policy is to confer with the hospital pharmacist on potential drug interactions.

Immunosuppressants such as cyclosporine and tacrolimus are associated with neuropsychiatric side-effects. Cyclosporine is associated with delirium and anxiety and may elevate serum lithium levels.

Corticosteroids, particularly at high doses, may be associated with a wide range of behavioural and psychiatric symptoms, from mild elation to frank psychosis. Steroids may destabilise pre-existing mental health problems. Advice may be sought regarding the use of steroid-sparing or steroid-avoiding regimes. The management has to be decided on a case-by-case basis. Drug treatment is determined by the patient's need for steroids, the availability of other treatment options, and the patient's clinical presentation and history. All need careful consideration.

Liaison psychiatrists may be asked to assist in the management of post-operative delirium because of their expertise in the use of antipsychotics. Low doses of typical antipsychotics such as haloperidol or atypicals such as risperidone or quetiapine can be used. If a benzodiazepine is required, a short-acting one with no active metabolites, such as lorazepam, is appropriate.