Psychosomatics 40:293-297, August 1999
© 1999 The Academy of Psychosomatic Medine
Psychiatric Disorders and Survival After Lung Transplantation
Catherine L. Woodman, M.D.,
Lois J. Geist, M.D.,
Sara Vance, R.N.,
Carolyn Laxson, R.N.,
Kelly Jones, M.S., and
Joel N. Kline, M.D.
Received May 6, 1998; revised September 14, 1998; accepted September 23, 1998. From the University of Iowa and Veterans Administration Hospital, Iowa City, Iowa. Address correspondence and reprint requests to Dr. Woodman, University of Iowa and Veterans Administration Hospital, 200 Hawkins Dr., Iowa City, IA 52242; e-mail: woodman.catherine_L{at}iowa-city.va.gov
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ABSTRACT
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The 30 patients who underwent lung transplantation between 1990 and 1996 were included in this study, and data were analyzed to find predictors of 1-year survival posttransplantation. All patients were followed throughout the posttransplantation period. Fifteen patients had a pretransplantation diagnosis of an anxiety and/or depressive disorders. Of the 30 patients transplanted, 19 survived 12 months or more, and 11 died less than 12 months posttransplantation. The >12-month survival group had a mean age of 45.2 years at transplantation, compared with a mean age of 43.0 years in the <12-month group (NS). The mean Psychosocial Assessment of Candidates for Transplant score and premorbid history of smoking did not differ between the groups. The >12-month survival group had more psychiatric illness pretransplantation than the <12-month survival group (56% vs. 27%, P<0.05). The recipients with a psychiatric history (N=15) were more likely to survive 1 year posttransplantation than the recipients without a psychiatric history (80% vs. 47%, P<0.05) and were not significantly different from the recipients without a psychiatric history in terms of episodes of rejection, bronchiolitis obliterans, or noncompliance with treatment. Depression and anxiety are treatable disorders that occur frequently in patients with end-stage lung disease, and a premorbid history of either did not predict a worse outcome posttransplantation in this study of lung transplantation recipients.
Key Words: Transplants • Syndromes Secondary to General Medical Disorders • Predictors of Outcome
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INTRODUCTION
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Lung transplantation is now performed for patients with a wide range of pulmonary diseases. Exclusion criteria vary from center to center, and include the presence of concurrent disease (e.g., coronary artery disease, malignancy, renal failure), previous chest surgery or trauma, nutritional state, functional status, and psychosocial issues.1,2 Although psychosocial contraindications to transplantation are difficult to quantify, active problems with cigarettes, alcohol, or illegal drug use have been felt to portend poor compliance with posttransplantation regimens and worsen the likelihood of successful transplantation.3 There are few data examining the impact of psychiatric diagnoses on transplantation outcomes and none specifically on survival in lung transplantation.
Psychiatric disorders are common in patients with end-stage lung disease who are candidates for lung transplantation.4 Craven et al. found that 50% of applicants for transplantation had a lifetime history of psychiatric illness.5 Lack of hope for the future, poor energy, poor sleep, and poor concentration are common in patients with end-stage lung disease. The limited literature available on the prevalence of psychiatric illness in the population of patients who are listed for lung transplantation show increased rates of lifetime psychiatric illness compared with control populations, but similar rates when compared with other end-stage disease populations.6
Posttransplantation patients must be compliant with antirejection medication and the medications that are used for immunosuppression, particularly prednisone, have been associated with increased psychiatric symptoms.7 Some centers have excluded patients with a history of psychiatric illness, believing that they will be less compliant posttransplant. It is not known if a premorbid history of psychiatric illness increases the risk of psychiatric disorders posttransplant, or if psychiatric illness is associated with poor compliance or worse survival.
There have been no reports of long-term outcome related to a pretransplantation history of psychiatric illness in lung transplantation recipients. We report the effect of pretransplantation psychiatric disorders on 1-year survival after lung transplantation.
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METHODS
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The lung transplantation program at the University of Iowa evaluated and transplanted patients from 1988–1996. Before 1990, a psychiatrist was consulted only when the presence of a psychiatric disorder was suspected. In 1990 a psychiatrist (CLW) joined the transplant team, and all prospective candidates were evaluated, regardless of symptoms. From 1990–1996, 135 patients were evaluated to be listed for transplantation, and 70 patients were listed. The 65 patients who were not listed were too ill to survive the waiting period, not ill enough to be listed for transplant, not interested in transplant once the initial evaluation was completed, or referred for lung reduction surgery. No patients were eliminated solely based on a psychiatric disorder. In addition to an evaluation of the medical necessity for lung transplantation, prospective patients for transplantation listing received a psychosocial evaluation. One of two nurse clinicians (CL, SV) and a licensed clinical social worker (KJ) with experience in evaluation of transplantation candidates conducted clinical interviews, which included an assessment of illness behavior, adjustment to illness, and psychosocial supports, as well as the applicant's understanding of the process of transplantation, the risks involved, and the posttransplantation course and potential problems. All patients were seen by a consultation-liaison psychiatrist (CLW) and underwent a Structured Clinical Interview for DSM-III-R (SCID)8 and the Psychiatric Assessment of Candidates for Transplantation (PACT)9 prior to being listed for transplantation. The SCID is a semistructured interview instrument that was developed to be used by experienced clinicians and trained researchers to make psychiatric diagnoses. The SCID has established reliability and is widely used. The instrument has one to three screening questions for each major psychiatric disorder. If one of the questions is answered affirmatively, additional questions are asked to gather information related to DSM-III-R criteria for that psychiatric diagnosis. The instrument yields threshold and subthreshold diagnoses. The SCID also allows for multiple psychiatric diagnoses to be made for the same patient. The SCID does not diagnose personality disorders or developmental disorders. The PACT is a clinician-rated instrument that assesses a transplant candidate in the areas of social support, psychological health, life-style factors, and understanding of transplant. The PACT rates a patient's suitability for transplant on a scale of 0 (poor, surgery contraindicated) to 4 (excellent candidate). All prospective transplantation patients were seen at the University of Iowa Hospitals and Clinics about every 6 weeks. The transplantation team included pulmonologists (JNK and LJG), cardiothoracic surgeons, nurse coordinators, a social worker, a dietitian, a psychologist, and a psychiatrist. The majority of patients underwent pulmonary rehabilitation, the exception being patients with severe pulmonary hypertension. Patients who had psychiatric illness were treated with medication and, in some cases, with psychotherapy as well.
Thirty patients received either a single or bilateral lung transplantation at the University of Iowa Hospitals and Clinics during the study period. All patients received their follow-up care at the University of Iowa Hospitals and Clinics from the same team of transplantation specialists who treated them pretransplantation.
Differences in categorical frequencies were crosstabulated in two-way tables and examined for independence by using chi-square tests. The relationships between continuous variables were examined by means of pairwise correlations by using two-tailed significance tests.
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RESULTS
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The demographic data for the 70 candidates listed for lung transplantation are listed in Table 1. There was not a significant difference between the number of men and women who were listed for transplantation. Significantly more candidates were married or involved in stable relationships than were not (P<0.0001). There were significantly more candidates with chronic obstructive pulmonary disease and pulmonary hypertension than other diagnoses (P<0.01) (see Figure 1). Psychiatric illness was prevalent in this group of patients (Table 1). Major depressive disorder and generalized anxiety disorder were most common, and some candidates had more than one psychiatric diagnosis. All patients with psychiatric illness were treated pretransplantation, with partial (41.4%) to complete (58.6%) remission of their psychiatric symptoms. The average length of time from listing to transplantation was 10.5 months (range: 1–28 months).
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TABLE 1. Demographics and DSM-III-R psychiatric disorders in 70 consecutive patients listed for lung transplantation
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Of the 70 candidates listed for transplant, 30 patients underwent single or bilateral lung transplantation. There were no demographic differences between those who underwent transplantation and those who did not. The mean age was 44.4 years, and 63% of the recipients were male. There were no significant differences in pulmonary diagnoses or lifetime history of psychiatric disorders between the two groups (see Table 2). The 40 patients who were listed but not transplanted at our center died before transplant (n=22), were on the transplant list when the program closed (n=10), or were referred to another center to be transplanted (n=8).
The average hospital stay posttransplantation was 52 days (range 21–114). Four patients had either intraoperative death or died prior to leaving the hospital postoperatively. A total of 11 recipients survived less than 12 months (Figure 2: Kaplan-Meier survival curve).
The 30 patients were divided into two groups, those who survived more than 12 months and those who did not survive 12 months, to find predictors of survival. There were no significant differences between the two groups related to age, educational level, or smoking history. The 1-year survivors had more psychiatric illness (56% vs. 27%, P<0.05). There were more males among the survivors (72% vs. 56%, P<0.05). PACT assessments were not significantly different between the two groups (2.88 vs. 3.02, NS).
The outcome of transplantation for the recipients with psychiatric illness (n=15) was compared with the recipients without psychiatric illness (n=15). The recipients with a history of anxiety and depression were more likely to survive 1 year (80% vs. 47%, P<0.05). There were no significant differences between the groups in pulmonary diagnosis, age, gender, or educational level. Among the survivors, the patients with a previous psychiatric illness were less likely to return to work than those without a premorbid history of psychiatric illness. But the numbers were small, and this factor did not reach significance (41.7% vs. 57.1%, NS).
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DISCUSSION
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This study demonstrates that a pretransplant psychiatric diagnosis does not necessarily worsen survival following lung transplantation. The study has several limitations. First, it has a small number of transplanted patients, and an even smaller number of patients who survived, so while these results are reassuring, they need to be replicated by other centers. In addition, the transplanted patient population was a selected population. The recipients in this study were screened for psychiatric disorders and psychosocial support before being listed for transplantation and treated before surgery. Not all patients experienced illness remission prior to transplant, and remission was not a precondition of being listed for transplantation. However, all had at least some improvement in symptoms as well as function, including improved energy and better compliance with exercise. The lack of difference in PACT scores for those with a history of psychiatric disorders, compared with those without a history, suggests that the patients with psychiatric disorders had certain strengths, such as substantial psychosocial support. The outcome may have been different with a less carefully screened and treated group of patients.
In this study, of the patients who underwent lung transplantation the presence of psychiatric illness pretransplantation did not adversely affect 1-year survival. In fact, we found that lung transplant recipients with a prior history of psychiatric illness were significantly more likely to survive 1-year posttransplant. The numbers in this study are small (15 patients in each group) , so to draw broad conclusions from these data would be unwise. A possible explanation for this finding is that recipients with a history of psychiatric disorder may be better able to identify and face psychological difficulties; therefore, they are better prepared to cope with the significant stressors that occur posttransplantation. If this finding is replicated at other centers, the connection deserves further study.
Comparing the results of this study with prior studies is difficult. There are great differences in the psychosocial criteria that are used among transplantation centers, and there have been few studies that have reported the effect of premorbid psychiatric disorders on the outcome and survival of transplantation recipients in general and none that specifically address survival of lung transplantation patients.10–12 The literature that does exist is equivocal. There has been one study of quality of life in lung transplantation candidates,11 but patients with psychiatric disorders were not listed for transplantation, so comparison with our study is not possible. There are studies that report the outcome of liver, heart, renal, and pancreas transplantation related to psychosocial factors,3,13–18 and some studies that have combined data for several organs and reported on the whole.2 The impact that psychiatric disorders have on survival and return to work posttransplantation is mixed in these reports, with some showing that psychiatric illness adversely affects outcome, whereas others do not. Older studies contained more highly selected patient populations, and in a few studies the diagnosis of patients with a pretransplant history of psychiatric illness was made with a structured diagnostic instrument. In addition, the data related to psychiatric disorders and kidney transplantation may not have a direct bearing on lung transplantation. The patient populations for different organ transplantations do not have the same premorbid risks for psychiatric disorders. End-stage lung disease is associated with anxiety,19 whereas end-stage liver disease is associated with alcohol dependence,20 and end-stage heart disease is associated with depression.21 As an example, the presence of depression may not adversely affect the outcome of lung or liver transplant recipients, but, because of the pathophysiology of cardiovascular disease, may have a significant effect on heart transplant recipients. Therefore, the specific psychiatric disorders and their impact on posttransplantation outcome may be specific to the organ transplanted.
Pretransplantation depression or anxiety may adversely affect the ability to return to work posttransplantation. Half of the patients in our study who survived 1 year or more were able to return to work, but the total number of recipients was too small to make correlations between prior psychiatric illness and the ability to return to work. This factor has not been well studied in patients with lung transplantations. Paris and associates studied 250 patients who had undergone heart transplantation and found that the patients' self-perception of themselves pretransplantation influenced their return to work as well as the length of medical disability pretransplantation and the loss of health insurance and/or disability income.18 The patients' self-perceptions could be influenced by psychiatric disorders. In addition, the patients with psychiatric illness were unable to work earlier in the course of their illness than those without psychiatric illness, and the longer period out of work may have negatively contributed to their ability to get work posttransplant. The poor return-to-work rate was not accounted for by active psychiatric symptoms in either group of patients.
Quality of life after lung transplantation has not been well studied, and is another area where untreated psychiatric illness could affect the success of the transplantation. Half the lung transplant candidates in our study had a psychiatric disorder, with some candidates having a history of two disorders. Estimates of the prevalence of anxiety and other psychiatric disorders in patients with end-stage pulmonary illnesses range from 40% to 70%, which are well above the prevalence of psychiatric illness in the general population. In many cases, the psychiatric disorder follows the development of severe respiratory disease and may be a result of the dyspnea and chronic illness. Depressive and anxiety disorders are very responsive to treatment, with patients improving both psychiatrically and physically pre- and posttransplant. Optimizing the psychiatric health of lung transplantation candidates before transplantation is necessary, both to optimize the quality of life for patients with end-stage illness who do not survive to be transplanted and to improve outcome posttransplantation. This preliminary study demonstrates that the presence of a treatable affective disorder in a prospective candidate should not be the basis of exclusion from consideration for lung transplantation, and a preoperative diagnosis of a psychiatric disorder did not predict a worse outcome posttransplantation.
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ABSTRACT
INTRODUCTION
