Psychosomatics 40:503-509, December 1999
© 1999 The Academy of Psychosomatic Medine
Psychological Symptom Levels and Their Correlates in Lung and Heart-Lung Transplant Recipients
Carol S. Stilley, Ph.D.,
Mary Amanda Dew, Ph.D.,
Arthur A. Stukas, Ph.D.,
Galen E. Switzer, Ph.D.,
Jan D. Manzetti, R.N., Ph.D.,
Robert J. Keenan, M.D., and
Bartley P. Griffith, M.D.
Received January 13, 1999; revised April 27, 1999; accepted May 12, 1999. From the Departments of Nursing, Psychiatry, Epidemiology, Psychology, Medicine, and Surgery (Cardiothoracic Transplantation Division), University of Pittsburgh School of Medicine and Medical Center. Address correspondence and reprint requests to Dr. Stilley, 3500 Victoria Street, Room 460, Pittsburgh, PA 15261; e-mail: css100+{at}pitt.edu
|
ABSTRACT
|
This study examined depression, anxiety, and anger-hostility symptom levels, as well as overall quality of life, in a cohort of 50 lung and heart-lung transplant recipients. Only the subjects' mean anxiety symptoms were substantially elevated over normative levels. However, nearly half of the sample showed clinically significant distress in one or more of the three symptom areas. Pretransplant psychiatric history, educational level, posttransplant caregiver support, and health concerns were the most important independent correlates of the recipients' psychological outcome. Low sense of mastery and poorer physical functional status also showed some evidence of association with mental health.
Key Words: Syndromes Secondary to General Medical Disorders • Transplant Recipients
|
INTRODUCTION
|
As in other fields of organ transplantation, establishing surgical techniques and medical treatment to ensure meaningful survival rates precedes the study of the psychosocial aspects of lung transplantation. The 1996 1-year survival rate was 70% for lung recipients and 60% for heart-lung recipients; 5-year survival rates were 50% for lung recipients and 40% for heart-lung recipients.1 While these rates are lower than for some other types of solid-organ transplants, these figures are significant in that none of these patients would have survived for an extended period without transplantation.
Most of the psychosocial literature on lung transplantation focuses on global or physical-functional quality of life.2,3 Although this literature is less extensive than that on most other transplant populations, it is similar in demonstrating marked improvement in overall function posttransplant.4 In fact, the lung recipients in one study reported higher general functioning than the heart or liver transplant recipients.5 In contrast to the relatively detailed considerations of physical function, mental health outcomes among lung recipients have generally been measured only as part of broad quality-of-life instruments or with brief situational mood measures.4,6,7
The present study provides evidence relevant to issues of posttransplant psychological outcomes, using semistructured diagnostic interviews and a battery of instruments specifically chosen to focus on variables pertinent to emotional quality of life among transplant recipients.
Some psychological aspects of end-stage lung disease and transplantation may differ from other transplant experiences in important ways because of the nature of respiratory pathology, the broader age range of lung transplant patients, and the relatively higher incidence of disease onset in childhood. Four general diagnostic categories of lung conditions are amenable to transplantation in adults: cardiopulmonary vascular diseases (such as congenital anomalies and hypertension), restrictive diseases (such as pulmonary fibrosis and environmental/occupation-related conditions), obstructive diseases (such as emphysema), and suppurative diseases (such as cystic fibrosis).8 The onset of a congenital disease and cystic fibrosis is generally in childhood and reaches end stage in early adulthood; the other diseases typically reach terminal stages in middle to late adulthood.
The incidence of anxiety and panic disorders appears to be higher among patients with serious lung disease, compared with patients with other major chronic diseases amenable to organ transplantation.9 It is unknown, however, whether anxiety symptoms are also prominent in lung patients who have received transplants.
This study examines posttransplant anxiety, depression, and overall life quality, along with a number of pertinent demographic and psychosocial factors, that have been shown to be predictive of psychological functioning in other types of organ transplant recipients.10–12 Specifically, family and/or personal psychiatric history, lower levels of social support, self- esteem and sense of mastery, and increased impairment in physical functioning and health-related worry are hypothesized to be associated with greater psychological distress and lower life satisfaction in this cohort.
|
METHODS
|
Respondents
The subjects were 50 patients returning for routine posttransplant clinic visits at the University of Pittsburgh Medical Center's Cardiothoracic Transplantation Program. Thirty-six lung recipients were selected at random from the pool of all lung recipients returning for follow-up clinic visits during their first 18 postoperative months; five additional recipients refused to participate. The lung recipients were transplanted between November 1992 and July 1993. Fourteen heart-lung recipients were recruited from all patients who survived this procedure between April 1990 and October 1995 (one recipient of the pool of 15 refused to participate) during a separate study that overlapped with collection of data from the lung recipients. All subjects were interviewed when they returned for routine follow-up clinic visits during their first 12 postoperative months. The total sample of 50 transplant recipients was interviewed anywhere from 2.5 to 17 months postoperatively (mean: 11.3 months). (Length of time since transplantation was not significantly correlated with any of the outcome variables and was therefore not included in the multivariate analysis.) The distribution of indications for transplant in the sample mirrored the distribution worldwide for lung and heart-lung recipients.1Table 1 provides the characteristics of subjects, according to the type of transplant. The two groups were similar on most characteristics, except that the lung transplant recipients were significantly older than the heart-lung recipients. Although the differences are nonsignificant, the lung recipients also were more likely to report a positive family psychiatric history and (as indicated by the 6-minute walk test, described next) to have less functional lung capacity.
Procedure
Face-to-face interviews with transplant recipients were arranged to coincide with routine follow-up visits and were conducted in the outpatient clinic. Informed consent was obtained before the interviews. Sessions were individual and lasted about 90 minutes. The interviewers had graduate degrees and clinical experience in a mental health field and had been trained in the assessment battery and monitored for reliability.
Instruments
Psychological Distress and Well-Being.
Psychological distress was measured with the anxiety, depression, and anger-hostility subscales of the Symptom Checklist-90 (SCL-90).13 Items are rated on a 5-point scale (0=not at all distressed to 4=extremely distressed). These subscales of the SCL-90 were selected because, in contrast to remaining subscales, they include fewer somatic items and other types of items that are inappropriate for patients with chronic illness (e.g., the item "the idea that something serious is wrong with your body" on the psychoticism scale). We examined each subscale as a continuous variable, to compare our sample with the normative mean; means for each domain were log-transformed to reduce skewness for significance testing. We also created dichotomous variables for each symptom subscale to identify which patients showed a clinically significant elevation of the scale (exceeding one standard deviation above the gender- specific normative mean).13 Finally, we created an overall "psychological distress" measure to identify patients who had a clinically significant elevation in any one of the three symptom areas.
Overall life quality was measured with the Campbell Sense of Well-Being Scale.14 The transplant recipients were asked to rate the quality of their lives, using eight (AUTHOR: or 9) 7-point semantic differential scales of polarized adjectives such as "boring-interesting", "hard-easy." The subjects also responded in similar fashion to a global item reflecting overall life satisfaction. A new variable "Overall Life Quality"14 was then computed to represent an average of the nine Campbell scales. Overall life quality was examined as a continuous variable for comparison of the groups with the normative mean and according to type of transplant. For ease of interpretation, the variable was dichotomized to categorize the patients as having either high or low levels of overall life quality (using a median split) for use in further analyses.
Background Characteristics and Psychological Correlates to Well-Being.
Age, gender, and educational level were reported as part of a complete demographic profile. Waiting time before transplant and pretransplant 6-minute walk time were obtained by chart review. The 6-minute walk test15 is a standardized procedure that measures distance walked, heart rate, and arterial oxygen saturation; distance walked provides a useful and valid measure of functional capacity.16
Family psychiatric history was determined with a brief portion17 of the Renard Diagnostic Interview.18 The subjects reported on the incidence, among first-degree relatives, of psychiatric disorders such as depression, anxiety, psychosis, substance abuse, and hospitalizations. Each subject's own history of major depression or generalized anxiety disorder before the transplant was determined with the Structured Clinical Interview for DSM III-R.19 These disorders were assessed because anxiety and depression are the most commonly reported psychiatric problems throughout the transplant process.20,21
Two areas of social support were examined. Caregiver support was measured with a 20-item questionnaire modeled on the work of Spanier22 and Pearlin and Schooler.23 This instrument elicits information about the quality of the relationship between the recipient and whomever he/she identifies as his/her primary family caregiver (usually the spouse). Friend support was assessed with a 14-item measure adapted from Moos' work24 on the degree the respondents felt they could rely on friends for emotional and practical support.
Two measures of self-image were included. Self-esteem and self-perceptions of competence about the ability to manage one's circumstances were assessed with the 10-item Self-Esteem Scale25 and the 7-item Sense of Mastery Scale.23
Impairment in activities of daily living was measured with selected items from the Sickness Impact Profile (SIP).26 The SIP measures illness-related dysfunction; subscales reflecting difficulty with sleep and rest, body care and movement, ambulation, and mobility were used in this study. These subscales were averaged to obtain an overall measure of impairment.
Health-related worry was measured with several questions about illness-related stress originally developed and used with kidney transplant recipients.27 Items addressed how often the recipients had recently been concerned or worried about being a burden to their families, worried about finances, graft rejection, infection, the need for retransplantation, or other health problems. Items were summed to assess the number of domains about which the subjects worried.
The six psychosocial variables all had skewed distributions. Each variable was therefore dichotomized by using a median split to reduce skewness and to categorize the recipients as generally being more or less vulnerable to psychological distress and as having high or low overall life quality.
Analysis.
Descriptive data for the psychological distress variables are presented for the entire sample and according to type of transplant. Distress levels in this sample were compared with distress levels in the normative, nonpatient community cohorts; the subjects were also compared on levels of clinically significant psychological symptomatology according to type of transplant. Cross-tabulation of background characteristics (including type of transplant) and psychosocial variables with posttransplant psychological distress and overall life satisfaction were then examined. Characteristics that showed at least a modestly strong association with the psychological distress measures and life satisfaction in these cross-tabulations (effect size, phi > 0.25) were then entered into a separate, multiple, logistic- regression analysis to determine their unique relationships with those measures, controlling for other correlates.
|
RESULTS
|
Posttransplant psychological distress was examined in two ways. Mean scores on the depression, anxiety, and hostility subscales of the SCL-90 and on the overall quality-of-life measure are presented in Table 2, along with the data from nonpatient community samples. While there were no differences within our sample between the lung vs. heart-lung recipients on the measures, the group of recipients as a whole endorsed significantly higher levels of anxiety and lower levels of hostility than the normative sample. There were no significant between-group differences in depression or overall life quality.
Second, to examine clinically significant distress in the cohort, we determined the proportions who scored at least one standard deviation above the normative mean on the SCL-90 subscales. These proportions are presented in Table 3. On average, one would expect that about 16% of any given sample would score in the clinically significant elevated distress range.13 The present sample showed rates of depression (26.5%) and anxiety (34.7%) that were significantly higher than this expected proportion. Furthermore, within our sample, the lung recipients had higher rates than the heart-lung recipients in both of these areas; this between-group difference was significant for depression. Overall, 49% of the total sample (55.6% of the lung recipients, 30.9% of the heart-lung recipients) scored in the clinically significant range on at least one of the three SCL-90 subscales.
View this table:
[in this window]
[in a new window]
|
TABLE 3. Proportions of sample with clinically significant3 depression, anxiety, or hostility or posttransplant psychological distress
|
Cross-tabulations of the respondents' background characteristics and psychosocial factors with their scores on the two main psychological outcome measures, determined by chi-square analyses, are shown in Table 4. Chi-squared tests were conducted to compare each pair of proportions. The transplant recipients in the high psychological distress category were significantly more likely to have a personal history of depression and/or anxiety disorders before transplant. They were also more likely to report lower social support from family caregiver and from friends, a low sense of mastery, a higher level of health-related concerns, and more difficulty with activities of daily living. The patients with a low level of overall quality of life also reported significantly lower caregiver support, self-esteem, and sense of mastery, as well as higher levels of health concern and more difficulty with activities of daily living.
View this table:
[in this window]
[in a new window]
|
TABLE 4. Associations of psychological distress and low overall life quality with background characteristics and psychosocial variables (percentages by chi-square analysis)
|
Background characteristics and psychosocial variables related to psychological distress and life satisfaction at phi > 0.25 (the effect size associated with the chi-square tests performed for Table 4) were entered as independent variables into separate logistic regression analysis for each psychological outcome. (Six-minute walk time was correlated with life satisfaction at phi=0.29 but was not entered into the analysis because of missing data (N=19). Prior to these analyses, the independent variables were examined for multicollinearity (which could have compromised the analysis). Self-esteem was highly correlated with sense of mastery (r=0.71) and was eliminated from the analysis; this decision was based primarily on the evidence that sense of mastery is more directly related to managing posttransplant problems and would thus be more pertinent to this study.28 Caregiver support and problems with activities of daily living were correlated at 0.43 but were retained because they measure diverse constructs and because the correlation was not unduly large for multivariate analysis.29 None of the other variables in the regression were highly correlated; the median r was 0.07.
Results of the regressions are presented in Table 5. After controlling for the impact of other variables in the equation, the recipients with a history of depression/anxiety disorders before transplant remained significantly more likely to have elevated psychological distress posttransplant. Although not statistically significant, low caregiver support and a high level of health-related concerns were marginal effects on psychological distress. With regard to overall life quality, the recipients with a lower educational level, low caregiver support, and a high level of health-related concerns were considerably more likely to report low global life quality after controlling for the other variables.
View this table:
[in this window]
[in a new window]
|
TABLE 5. Regression coefficients (and standard errors) indicating effects of selected background characteristics and psychosocial correlates on posttransplant psychological distress and overall life quality
|
|
DISCUSSION
|
Our observations of an elevated mean level of anxiety in the present sample, and of a sizable proportion with clinically significant anxiety, are not only consistent with evidence that anxiety symptoms and diagnosable disorders are highly prevalent in persons with chronic lung disease,9 but also indicate that such distress remains relatively common even after transplantation. While the mean level of depression in the total sample was not significantly higher than the normative sample, the proportion of recipients with clinically meaningful depression was relatively large. It is noteworthy that the subset of patients reporting clinically significant levels of depression were all lung recipients; this finding, along with the fact that the lung patients were also more likely to have elevated anxiety levels, merits further study.
In contrast, the total sample's mean for hostility symptoms was significantly lower than the community norms; similar findings have been reported for heart recipients during the first year posttransplant.11 The transplant recipients may be repressing or denying any feelings of anger during a period when they are particularly dependent on others for support and survival. Alternatively, they may be so focused on their medical condition during the first year posttransplant that they are less likely to experience hostility or engage in hostile or aggressive behaviors.
While current psychological state and context does bias retrospective reports of past distress, the evidence that pretransplant psychiatric disorder was a particularly robust predictor of posttransplant distress in this cohort conforms to other study results with heart, kidney, and liver transplant recipients.12–14 Furthermore, as we have discussed elsewhere, there are numerous reasons why data about psychiatric history collected while individuals are awaiting transplantation are fraught with biases.11,30 The ability to draw on social supports from a variety of sources, including family, caregivers, and friends, appeared to be important for both psychological distress posttransplant and for perceived life quality; this finding also conforms to results from other studies done with other transplant recipients.12–14 Of course, in our sample, as in other transplant cohorts, levels of social supports are also related to other psychosocial characteristics that recipients bring to the posttransplant situation.30,31 Even after a variety of such other characteristics were controlled, caregiver support remained significantly related to overall life quality and was marginally associated with psychological distress. In this context, it is interesting to note that the greater the level of physical function limitations in daily life experienced by the recipient, the more likely it was that this individual reported a strongly supportive relationship with the caregiver (r=0.43).
Among the remaining psychosocial variables, a high level of health-related concerns appeared to be most robustly related to the recipients' psychological status, after other variables were controlled. The impact of this variable on perceived quality of life demonstrates the continued salience of this factor in the lives of transplant recipients, even well after initial perioperative recovery.
A final important result of our analyses was our general finding of very few differences between the lung and heart-lung patients. Although the lack of statistical significance could be partially due to a small sample size, the sizes of the effects involved were small, indicating instead that some aspects of organ transplantation are likely to be shared regardless of the medical diagnosis. These similarities across types of transplant patients, identified by research such as this, allow clinical professionals, who often cover several transplant services, to have a broader area of expertise within their transplant centers. Similarities may also support the development of general guidelines for selection criteria and treatment protocols between centers.
The main limitations of this study are our sample size and cross-sectional design. A larger sample size would have provided us with greater power for examining the statistical reliability of relationships between the psychological dimensions of posttransplant quality of life and background/psychosocial characteristics. Longitudinal study of this population would yield information about the extent to which the psychosocial characteristics that we examined were primarily predictors, as opposed to correlates—or even sequelae—of psychological and physical well-being posttransplant. It is important to note, however, that large samples are uncommon in this transplant group and that correlational designs are necessary to inform prospective studies. Furthermore, in terms of modifying those characteristics, while some of them were fixed (such as gender, age), others may be amenable to treatment both pre- and posttransplant. For instance, anxiety and depression pretransplant are often undiagnosed and go untreated. Social supports can often be located and/or improved; a low sense of mastery, a high level of worry, and physical difficulties with activities of daily living may be amenable to psychotherapy and social/educational interventions or physical rehabilitation interventions.
There is a growing body of evidence that outcome and survival after organ transplantation are affected by a number of nonmedical factors.32 This study provides descriptive data about background characteristics and psychosocial correlates to posttransplant psychological distress and overall life quality among lung and heart-lung transplant recipients, adding further depth to earlier work with this understudied population.
|
ACKNOWLEDGMENTS
|
This research was partially funded by a grant (Grant No. MH45020) from the National Institute of Mental Health, Rockville, MD.
|
REFERENCES
|
-
Hosenpud JD, Bennett LE, Keck BM, et al: The registry of the international society for heart and lung transplantation: fourteenth official report 1997. J Heart Lung Transplant 1997; 16:691–712[Medline]
-
Caine N, Sharples LD, Dennis C, et al: Measurement of health- related quality of life before and after heart-lung transplantation. J Heart Lung Transplant 1996; 15:1047–1058
-
Gross CR, Savik K, Bolman RM, et al: Long-term health status and quality-of-life outcomes of lung transplant recipients. Chest 1995; 108:1587–1593
-
Dew MA, Switzer GE, Goycoolea JM, et al: Does transplantation produce quality-of-life benefits: a quantitative review of the literature. Transplantation 1997; 64:1261–1273
-
Littlefield C, Abbey S, Fiducia D, et al: Quality of life following transplantation of the heart, liver, and lungs. Gen Hosp Psychiatry 1996; 18(suppl):36S–47S
-
Craven JL, Bright J, Dear CL: Psychiatric, psychosocial, and rehabilitative aspects of lung transplantation. Clin Chest Med 1990; 11:247–257[Medline]
-
Cohen L, Littlefield C, Kelly P, et al: Predictors of quality of life and adjustment after lung transplantation. Chest 1998; 113:633–644[Abstract/Free Full Text]
-
Smith CM: Patient selection, evaluation, and preoperative management for lung transplant candidates. Clin Chest Med 1997; 18:183–197[Medline]
-
Karajgi B, Rifkin A, Doddi S, et al: The prevalence of anxiety disorders in patients with chronic obstructive pulmonary disease. Am J Psychiatry 1989; 147:200–201[Abstract/Free Full Text]
-
Devins GM, Mann J, Mandin H, et al: Psychosocial predictors of survival in end-stage renal disease. J Nerv Ment Dis 1990; 178:127–133[Medline]
-
Dew MA, Simmons RG, Schulberg HC, et al: Psychosocial predictors of vulnerability to distress in the year following heart transplantation. Psychol Med 1994; 24:929–945[Medline]
-
Surman OS: Psychiatric aspects of liver transplantation. Psychosomatics 1994; 35:297–307[Abstract/Free Full Text]
-
Derogatis LR: SCL-90-R: Symptom Checklist 90-Revised: Administration, Scoring, and Procedures Manual. Towson, MD, Clinical Psychometrics Research, 1994
-
Campbell A, Converse PE, Rodgers WL (eds): The Quality of American Life: Perceptions, Evaluations, and Satisfactions. New York, Russell Sage Foundation, 1976
-
McGavin CR, Gupta SP, McHardy GJR: Twelve-minute walking test for assessing chronic disability in chronic bronchitis. BMJ 1976; 1:822–823
-
Manzetti JD, Hoffman LA, Sereika SM, et al: Exercise, education and quality of life in lung transplant candidates. J Heart Lung Transplant 1994; 13:297–305[Medline]
-
Bromet EJ, Dunn LO, Connell MM, et al: Long-term reliability of lifetime major depression in a community sample. Arch Gen Psychiatry 1986; 43:435–440[Abstract]
-
Helzer JE, Robins LN, Croughan JL, et al: Renard Diagnostic Interview: its reliability and procedural validity with physicians and lay interviewers. Arch Gen Psychiatry 1981; 38:393–398[Abstract]
-
Spitzer RL, Williams JBW, Gibbon M, et al: The Structured Clinical Interview for DSM-III-R (SCID): history, rationale, and description. Arch Gen Psychiatry 1992; 49:624–629[Abstract]
-
Freeman AM, Folks DG, Sokol RS, et al: Cardiac transplantation: clinical correlates of psychiatric outcome. Psychosomatics 1988; 29:45–54
-
Mai FM, McKenzie FN, Kostuk WJ: Psychiatric aspects of heart transplantation. BMJ 1986; 292:311–313
-
Spanier GB: Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. Journal of Marriage and Family 1976; 38:15–30
-
Pearlin L, Schooler C: The structure of coping. J Health Soc Behav 1978; 19:2–21[Medline]
-
Moos RH: Evaluating Correctional and Community Settings. New York, John Wiley & Sons, 1975
-
Rosenberg M: Society and the Adolescent Self-Image. Princeton, NJ, Princeton University Press, 1965
-
Bergner M, Bobbitt RA, Carter WB, et al: The Sickness Impact Profile. Med Care 1981; 19:787–805[Medline]
-
Simmons RG, Marine SK, Simmons RL: Gift of Life: The Effect of Organ Transplantation on Individual, Family, and Societal Dynamics. New Brunswick, CT, Transaction Books, 1987
-
Ell KO, Mantell JE, Hamovitch MB, et al: Social support, sense of control, and coping among patients with breast, lung, or colorectal cancer. Journal of Psychsocial Oncology 1989; 3:63–89
-
Tabachnick BG, Fidell LS: Using Multivariate Statistics, 3rd Edition. New York, Harper Collins, 1996
-
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(supp l6): 48S–61S
-
Hathaway DK, Winsett RP, Johnson C, et al: Post-kidney transplant quality-of-life prediction models. Clin Transplant 1998; 12:168–174[Medline]
-
Dew MA, Kormos RL, Roth LH, et al: Early post-transplant medical compliance and mental health predict physical morbidity and mortality 1–3 years after heart transplantation. J Heart-Lung Transplant 1998; 18:549–562
This article has been cited by other articles:
|
|
|
|
 
A. Hategan, C. Nelson, and S. Jarmain
Heart Transplant, Social Support, and Psychiatric Sequelae: A 10-Year Follow-Up Clinical Case Review
Psychosomatics,
February 1, 2008;
49(1):
39 - 41.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. A. Barbour, J. A. Blumenthal, and S. M. Palmer
Psychosocial Issues in the Assessment and Management of Patients Undergoing Lung Transplantation
Chest,
May 1, 2006;
129(5):
1367 - 1374.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. I. Parekh, J. A. Blumenthal, M. A. Babyak, K. Merrill, R. M. Carney, R. D. Davis, and S. M. Palmer
Psychiatric Disorder and Quality of Life in Patients Awaiting Lung Transplantation
Chest,
November 1, 2003;
124(5):
1682 - 1688.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 1999
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
