Psychiatric aspects of organ transplantation
- John Vella, MD, FACP, FRCP, FASN
John Vella, MD, FACP, FRCP, FASN
- Associate Professor of Medicine
- Tufts University School of Medicine
The development of end-stage organ failure combined with the realization that life may no longer be possible without medical intervention can lead to depression, anxiety, noncompliance with diet or medication, and sexual dysfunction in the transplant patient . The administration of immunosuppressive drugs, such as glucocorticoids and cyclosporine, has also been implicated in causing psychiatric disturbances [2,3]; these include euphoria, delirium, generalized anxiety disorder, and hallucinosis.
These disorders frequently require treatment with psychopharmacologic agents. However, their administration may be hazardous because of adverse effects as well as specific interactions with immunosuppressive drugs.
This topic review will discuss some of the more common psychiatric disturbances that develop in transplant recipients with specific attention to their impact upon pharmacologic management and prognosis. Discussions related to psychotherapy are presented separately.
PSYCHOLOGICAL IMPACT OF TRANSPLANTATION
The altruistic act of kidney donation appears to confer psychologic benefit to the donor. In a study of donors followed after a period of 5 to 10 years, the majority of individuals, independent of the outcome of the procedure, expressed positive feelings towards having donated a kidney . However, in another survey, donating was perceived to have had a negative impact upon the health and finances of 15 and 23 percent of responding donors, respectively . Despite this perception, donors of kidneys live longer than others, due most probably to the screening process, which only permits healthy persons to be accepted for living kidney donation .
For the graft recipient, transplantation means more than an operation; it requires a certain degree of personal strength and adequate coping skills. In a study of heart transplant recipients, patients were grouped according to their response to a psychological survey :
- Stewart RS. Psychiatric issues in renal dialysis and transplantation. Hosp Community Psychiatry 1983; 34:623.
- Sharma VK, Enoch MD. Psychological sequelae of kidney donation. A 5-10 year follow up study. Acta Psychiatr Scand 1987; 75:264.
- Schover LR, Streem SB, Boparai N, et al. The psychosocial impact of donating a kidney: long-term follow-up from a urology based center. J Urol 1997; 157:1596.
- Fehrman-Ekholm I, Elinder CG, Stenbeck M, et al. Kidney donors live longer. Transplantation 1997; 64:976.
- Bunzel B, Wollenek G, Grundböck A. Living with a donor heart: feelings and attitudes of patients toward the donor and the donor organ. J Heart Lung Transplant 1992; 11:1151.
- Waterman AD, Stanley SL, Covelli T, et al. Living donation decision making: recipients' concerns and educational needs. Prog Transplant 2006; 16:17.
- Pradel FG, Limcangco MR, Mullins CD, Bartlett ST. Patients' attitudes about living donor transplantation and living donor nephrectomy. Am J Kidney Dis 2003; 41:849.
- McCabe MS, Corry RJ. Psychiatric illness and human renal transplantation. J Clin Psychiatry 1978; 39:293.
- Kiley DJ, Lam CS, Pollak R. A study of treatment compliance following kidney transplantation. Transplantation 1993; 55:51.
- Devins GM, Beanlands H, Mandin H, Paul LC. Psychosocial impact of illness intrusiveness moderated by self-concept and age in end-stage renal disease. Health Psychol 1997; 16:529.
- Dobbels F, Skeans MA, Snyder JJ, et al. Depressive disorder in renal transplantation: an analysis of Medicare claims. Am J Kidney Dis 2008; 51:819.
- Washer GF, Schröter GP, Starzl TE, Weil R 3rd. Causes of death after kidney transplantation. JAMA 1983; 250:49.
- Kurella M, Kimmel PL, Young BS, Chertow GM. Suicide in the United States end-stage renal disease program. J Am Soc Nephrol 2005; 16:774.
- Hilbrands LB, Hoitsma AJ, Koene RA. The effect of immunosuppressive drugs on quality of life after renal transplantation. Transplantation 1995; 59:1263.
- Dew MA, Roth LH, Schulberg HC, et al. Prevalence and predictors of depression and anxiety-related disorders during the year after heart transplantation. Gen Hosp Psychiatry 1996; 18:48S.
- Andrews JM, Nemeroff CB. Contemporary management of depression. Am J Med 1994; 97:24S.
- Stoudemire A. New antidepressant drugs and the treatment of depression in the medically ill patient. Psychiatr Clin North Am 1996; 19:495.
- DeVane CL. Pharmacokinetics of the newer antidepressants: clinical relevance. Am J Med 1994; 97:13S.
- Butler JA, Peveler RC, Roderick P, et al. Modifiable risk factors for non-adherence to immunosuppressants in renal transplant recipients: a cross-sectional study. Nephrol Dial Transplant 2004; 19:3144.
- Rosenthal JT, Danovitch G, Ettenger RB, Wilkinson A. Kidney transplantation at UCLA. Clin Transpl 1990; :255.
- Smith AY, Van Buren CT, Lewis RM, et al. Factors determining renal transplant outcome at the University of Texas at Houston. Clin Transpl 1987; :155.
- Burke G, Esquenazi V, Gharagozloo H, et al. Long-term results of kidney transplantation at the University of Miami. Clin Transpl 1989; :215.
- Matas AJ, Humar A, Gillingham KJ, et al. Five preventable causes of kidney graft loss in the 1990s: a single-center analysis. Kidney Int 2002; 62:704.
- Butler JA, Roderick P, Mullee M, et al. Frequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review. Transplantation 2004; 77:769.
- Vlaminck H, Maes B, Evers G, et al. Prospective study on late consequences of subclinical non-compliance with immunosuppressive therapy in renal transplant patients. Am J Transplant 2004; 4:1509.
- Dew MA, Kormos RL, Roth LH, et al. 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; 18:549.
- Greenstein S, Siegal B. Compliance and noncompliance in patients with a functioning renal transplant: a multicenter study. Transplantation 1998; 66:1718.
- Abbott KC, Agodoa LY, O'Malley PG. Hospitalized psychoses after renal transplantation in the United States: incidence, risk factors, and prognosis. J Am Soc Nephrol 2003; 14:1628.
- Shaw RJ, Palmer L, Blasey C, Sarwal M. A typology of non-adherence in pediatric renal transplant recipients. Pediatr Transplant 2003; 7:489.
- Weng FL, Israni AK, Joffe MM, et al. Race and electronically measured adherence to immunosuppressive medications after deceased donor renal transplantation. J Am Soc Nephrol 2005; 16:1839.
- Bunzel B, Laederach-Hofmann K. Solid organ transplantation: are there predictors for posttransplant noncompliance? A literature overview. Transplantation 2000; 70:711.
- Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353:487.
- Dunn TB, Browne BJ, Gillingham KJ, et al. Selective retransplant after graft loss to nonadherence: success with a second chance. Am J Transplant 2009; 9:1337.