Psychiatric and Psychosocial Aspects of Liver Transplantation

Liver transplantation (LT) has increasingly been accepted as the standard of care for patients with irreversible advanced liver disease. Due to an expanded list of diseases that are accepted as indications for transplantation, for example, specific criteria for hepatocellular carcinoma (HCC), coupled with a finite number of available organs, the national waiting list of patients has steadily grown. Nonetheless, the supply of donor organs has not kept pace, with currently 16% of patients dying on the waiting list without obtaining a transplant.1 This mortality rate has indicated a need to develop effective selection criteria for the more suitable candidates. Efforts to prepare patients so they are in the optimal state of physical and emotional health to adapt successfully after transplantation remain a priority. Recognizing the potential impact of psychiatric disorders, including addictions, on the liver transplant patient's outcome is essential. The aim of this article is to provide an overview the psychiatric disorders and issues with which the transplant hepatologist must be knowledgeable. In particular, this review evaluates how psychiatric and chemical dependency disorders may interfere with optimal adherence to recommended treatment and social support. In these complicated cases, psychiatric consultation can aid in the determination of the relative importance of a patient's psychiatric history and assist in preparing these individuals for transplantation. LT, liver transplantation; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; ALD, alcoholic liver disease; MMT, methadone maintained; PTSD, posttraumatic stress disorder; SSRIs, selective serotonin reuptake inhibiting antidepressants. The objective of the pretransplant evaluation is to ensure that the patient is appropriate for transplantation. The current one- and five-year survival rates after liver transplantation over time has steadily increased to 86% and 72%, respectively.1 Nevertheless, patient compliance with immunosuppressive medication has been directly implicated in acute and chronic rejection episodes in organ transplant patients in general,2-4 with chronic rejection being the leading cause of graft loss for liver transplant recipients.5, 6 In fact for all types of organ transplants, noncompliance is responsible for up to 25% of late deaths posttransplant.2 Although there are no data indicating whether specific psychiatric disorders per se are associated with shorter life expectancy after transplantation, the potential impact of any disease process on survival is in large part amplified or tempered by the patient's success in adhering to treatment recommendations. Nonadherence encompasses many domains, including medication (particularly immunosuppressives), clinic appointments, laboratory tests, self-monitoring (blood pressure, glucose), exercise, and the use of harmful substances (alcohol and drugs).7 The LT literature has primarily focused on medication nonadherence. Medication nonadherence has been observed to be higher in patients with less satisfactory outcomes, for example, those relapsing with alcohol use.8 With advances in clinical research, more effective but often complex treatment plans are in use. Current management of hepatitis C virus (HCV) with interferon and ribavirin serves as an example. For instance, patients with recurrent HCV post-LT will require combination therapy that includes weekly self-administered injections, oral medication, and frequent weekly laboratory testing. Longer life expectancy and improved quality of life than in the past have been attributed to newer regimes of self-administered injections, oral medication, and frequent laboratory testing. Patients who cannot adhere to this program are at risk of increased morbidity and mortality. When a patient has previously demonstrated an inability to conform to the recommendations for one disease process, the possibility of nonadherence with the multifaceted lifelong treatment plan after LT is increased. Thus, how the candidate has adapted to illness and adhered to pre-LT medical directives should be evaluated (Table 2). Given the mortality rate among candidates waiting for LT, the rejection or loss of a transplanted liver due to nonadherence is a tragedy. Many factors contribute to nonadherence, including cognitive impairment, inability to communicate, rebelliousness, arrogance, denial of illness, lack of motivation, hopelessness, and inadequate social support. These traits are more frequently identified in patients with psychiatric or chemical dependency disorders. In a study of heart transplant recipients, Dew et al. described an increased risk of nonadherence depending on the number of psychosocial risk factors (Fig. 1).7 The following sections of this article, subdivided into major categories, will address the influence of a variety of psychiatric and addictive conditions on adherence. An increase of nonadherence is associated with an increased number of psychosocial risk factors in heart transplant recipients. Psychosocial factors include hostility, poor support from caregivers, poor support from friends, failure to use active coping strategies, and use of avoidant coping strategies. Adapted from Dew et al.7 The presence of an enduring social network is required to assist a patient who is otherwise compromised in achieving satisfactory survival and quality of life during the transplant process. The support persons should be capable of providing a combination of basic cares, transportation, medication verification as well as emotional sustenance during a challenging episode of care. Many transplant programs require the well-documented availability of more than one support person in case the identified person becomes unavailable. The primary sources of support are required to be closely involved from the initial stages of assessment, through hospitalization and the postoperative period. More institutions offer a supportive living environment, often called transplant houses, where patients can stay while pursuing medical care. However, since nursing care is not a service provided by these facilities, they mandate that a support person stay with the patient to provide assistance. The availability of a good social support system has been considered to be predictive of lower risk for recidivism and nonadherence, whereas poor or absent social support indicates high risk.9 Marriages and committed relationships have been reported to stay intact throughout the transplant experience.10 Patients who perceive themselves to have social support have been observed to have lower rates of depression.11 A study of diabetic patients undergoing pancreas transplantation found higher rates of social support was correlated with longer graft function.12 Support at the time of LT evaluation is essential for patients with cognitive impairment due to hepatic encephalopathy to comprehend and implement treatment interventions.9 The presence of enduring social support is less common in particular for patients with active personality disorders.13 Features of untreated depressive disorders include social withdrawal, helplessness, and irritability than can seriously strain marriages or committed relationships. Depressed patients can also become estranged from their family of origin and lack involvement in work, faith, or community organizations that can lead to supportive friends. Likewise, patients with active chemical dependency issues can become isolated from family or other networks that have become frustrated with the persistent nature of the patient's alcohol and drug use. Cognitive impairment related to hepatitic encephalopathy can result in unpredictable and provocative behavior that tests the patient's associates. Socially isolated individuals present to transplant programs without awareness that LT is an intensely demanding physical and emotional dependence making total self-sufficiency inadvisable. These patients expect that the transplant team and resources such as supportive transplant housing, where will a transplant need to develop and for social support. and health can provide as to how a patient can or sources of support. However, should be this support is in liver disease is one of the common types of liver disease in the and is more common in to of with alcoholic liver disease for of LT recipients, making the common for liver more than individuals from chronic liver disease in in that less than individuals a liver transplant for These that a of patients with to transplantation. 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This has clinical for treatment recommendations and as the have selection criteria for patients with Many mandate a of as and available social and in for patients with to be considered as transplant candidates. 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