Psychosomatics 41:393-406, October 2000
© 2000 The Academy of Psychosomatic Medicine
The Structured Interview for Renal Transplantation—SIRT
DeAnna L. Mori, Ph.D.,
Patricia Gallagher, Ph.D., and
Judith Milne, M.D.
Received August 31, 1999; revised November 3, 1999; accepted February 2, 2000. From the Psychology Service, Boston VA Medical Center, Boston, MA. Address reprint requests to Dr. Mori, Psychology Service (116B), Boston VA Medical Center, 150 South Huntington Avenue, Boston, MA 02130.
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ABSTRACT
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Despite the fact that the demand for psychiatric evaluations of organ transplant recipients is increasing, there is not a commonly agreed upon protocol that can guide clinicians. A standard psychiatric interview, although necessary, is not sufficient when interviewing transplant candidates. In addition, it is important to acquire information specific to the medical regimen associated with renal disease and renal transplantation. The purpose of this paper is to present the Structured Interview for Renal Transplantation (SIRT). The SIRT was developed as a tool to guide clinicians through the interview process by providing a comprehensive structure while still allowing for flexibility. There are many advantages of using the SIRT—it is a tool that facilitates a clinician's ability to conduct a thorough evaluation in a time-efficient manner. It is also an excellent instrument for training clinicians, and the structure of the interview is appropriate for use in research.
Key Words: Transplant • Structured Interview • Evaluation
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INTRODUCTION
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Transplantation is commonly thought of as the optimal treatment for patients with end-stage renal disease (ESRD). However, the demand for renal transplantation far exceeds the number of kidneys that are donated each year.1–8 To optimize the allocation of this scarce resource, consultation-liaison (C-L) services are often consulted to evaluate patients' psychiatric appropriateness for transplantation.9 Psychiatric appropriateness is most often determined by clinical interview, and the interview is sometimes accompanied by psychological and cognitive testing. The objective of evaluation is to identify patients who could most effectively comply with the rigorous postoperative transplantation course because noncompliance can result in major medical problems or death.7,8,10–13 Psychiatric factors that are believed to impact compliance include mood, cognitive functioning, personality, and social support.12,14–18
Psychiatric assessment of renal transplant candidates is becoming increasingly necessary as more transplants are taking place. However, many C-L psychiatrists have not been trained specifically to conduct these types of assessments and are often uncertain about all the areas that need to be assessed. A standard psychiatric interview, although necessary, is not sufficient when interviewing these candidates. In addition to a psychiatric history, it is also important to acquire information specific to the medical regimen associated with renal disease and renal transplantation. Although psychiatric issues are important to assess, it is often the patients' behaviors that ultimately determine their appropriateness for transplantation from a psychiatric perspective.
Furthermore, Rundell and Hall19 found that renal transplant candidates have unique psychiatric characteristics. This highlights the importance of being adequately familiarized with the population when conducting a pretransplant psychiatric evaluation. For example, transplant candidates are less likely than C-L inpatients to report a past history of mental health treatment, equally likely to acknowledge past substance use, and more likely to be diagnosed with hypoactive sexual desire disorder. In one of the few longitudinal studies examining renal patients, some of whom received transplants, depression and age were the two most important predictors of survival when psychological, demographic, physical, and biochemical factors were considered.20
Despite the fact that the demand for psychiatric evaluations of renal transplant recipients is increasing, there is not a commonly agreed upon protocol that can guide clinicians.8,21,22 Even when there is consensus on which psychometric instruments should be administered, there tends to be minimal discussion about the core of the evaluation process—the clinical interview.
The purpose of this paper is to present the Structured Interview for Renal Transplantation (SIRT). The SIRT was developed as a tool to guide clinicians through the interview process by providing a comprehensive structure and allowing for flexibility. This instrument cues the interviewer to obtain necessary information that might otherwise be overlooked or forgotten. The SIRT highlights areas that are specific to kidney transplantation and gives clinicians an immediate understanding of what type of information is necessary to conduct a thorough evaluation. Additionally, the SIRT provides a way to assess the patients' behavioral compliance by guiding the clinician to address behavioral issues (e.g., medication compliance, attendance to appointments, and dietary compliance). It is also time efficient in that information is easy to record, and many questions can be answered simply by checking the appropriate response. Furthermore, having all the information documented in this structured manner facilitates the clinicians' ability to effectively assimilate the material.
Structured protocols are particularly useful in training environments in which residents and interns rotate through on a regular basis. Trainees often take on significant clinical responsibilities, and it can be an overwhelming challenge to quickly become an "expert" while working with a diverse range of patient populations. Gathering interview data in a structured and standardized manner increases the likelihood that relevant information will be obtained. Carefully gleaning and assimilating interview data are particularly crucial in this population of potential transplant recipients, given the magnitude of the decision being made. Furthermore, establishing a standardized assessment protocol would optimize the systematic collection of data that could be used to investigate psychological factors that are used in clinical decision making in transplantation.23–26
Although the SIRT can be a very effective guideline, it certainly does not take the place of didactics, training, or a good teacher. It is meant to be used as a guideline that can facilitate the educational and interviewing process. To be a truly effective clinician with this population, it is important to have good clinical judgment and skill, as well as a solid understanding of all the components addressed in the interview. Although many of the items on the SIRT are listed as a checklist, it is not suggested that it be administered in a "checklist" fashion or presented verbatim. For example, when assessing sensitive topics such as substance abuse or compliance, it is important for clinicians to rely on their own clinical judgment when framing questions.
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The SIRT
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Three psychologists developed the SIRT while working with transplant patients (see Appendix 1). Professionals from various medical centers across the country specializing in psychiatry, transplant surgery, neuropsychology, and clinical psychology critiqued the content that resulted in a 93-item instrument. The SIRT consists primarily of 7 sections: Background/Demographics, Understanding of Illness, Education/Socioeconomic Status, Brief Family History, Coping/Personality Style, Psychiatric History, and Mental Status Exam. The last two sections are not a part of the interview but provide a place to report Psychological Assessment scores and additional medical information. Below is a description of each section of the SIRT and the rationale for its inclusion.
- Background/Demographic Information. Basic demographic information is collected in this section, consisting of 12 items. Information such as age, gender, race, and emergency contact person is obtained.
- Understanding of Illness. This section contains 23 items that focus on the patients' understanding of their renal disease, their current medical and dialysis regimen, and their understanding of the transplant procedure. Patients answer questions about when they were diagnosed with kidney disease, the etiology of their kidney disease, and what additional medical diagnoses they may have. Information is obtained about their dialysis regimen, including when dialysis was initiated and the type of dialysis they are on. In addition to obtaining the patients' report of the above information, a chart review is conducted to verify the information. A chart review also provides the clinician with the opportunity to correct any misreported information.
The next part of this section focuses on the patients' knowledge of and compliance with their renal medical regimen. Their knowledge about their renal diet and medications is rated on a 5-point scale that ranges from 1 (poor) to 5 (excellent). In addition, patients are asked to provide self-reported ratings (on the same scale as above) of their compliance with their diet, medications, and appointments. Because self-report data are not always reliable, patients' self-report is corroborated with a chart review and staff report. These first two parts of this section help the clinician to assess how well the patients understand their current regimen and how compliant they have been with its demands.
The relationship between compliance with various aspects of a medical regimen and future compliance with the transplant regimen is complicated. It is unclear if past compliance necessarily predicts future success with transplantation. Furthermore, the reliability of self-report data can be questionable. Nonetheless, compliance information can be useful in assessing factors that can place a transplant recipient at risk.
The last part of this section focuses on the transplant procedure. Patients are provided with six common reasons people pursue transplantation (e.g., increased mobility and dietary choices, return to work, travel, improved health, improved sexual functioning), and the patients are asked to rate how important each of these reasons are in their decision to obtain a transplant on a scale ranging from 1 (not at all) to 5 (extremely). In addition, the patients' knowledge about various aspects of the transplant regimen (medications, risks associated with transplantation, postoperative course) is rated. This section allows the clinician to determine if the patients are properly informed and fully understand the transplant procedure.
To aid the interviewer, brief answers to some of the questions in this section appear in italics. Because it is likely that medications and the medical regimen may vary from site to site, these answers should be adapted to accurately reflect the medical regimen and transplant course specific to the institution.
- Education/Socioeconominic Status. This section outlines the patients' education, work history, and financial support. These 13 items address the impact renal disease has had on the patients' employment history and income. Also, the questions about the patients' educational history may alert the clinician to any learning barriers that may exist and potentially impact the patients' ability to learn about their current medical regimen.
- Brief Family History. There are 5 items in this section. The patients' family members and the quality of the relationships are assessed. The clinician assesses the family support that may be available to the patient.
- Coping/Personality Style. This 6-item section further assesses the supportive resources that are available to the patient. Patients describe their living situation and report on who provides them with emotional support and who will be available to provide posttransplant functional support. In addition, the patients' cognitive and behavioral adaptive strategies are identified, and clinicians are provided with a report of the patients' activities on a "typical" day. Clinicians can use this section to learn about patients' coping strategies and resources. This is very important in that going through the transplant procedure can be a very demanding and stressful process.
- Psychiatric History. This 15-item section first assesses the patients' self-reported history of psychopathology, psychiatric treatment, and substance use. Second, the patients' family history of psychiatric problems and substance use are also evaluated. All items are verified by a chart review.
- Mental Status Exam. There are 19 items included in the Mental Status Exam. The patients' orientation, mood, sleep, energy level, homicidal and suicidal ideation, and psychotic symptomatology are assessed.
- Additional Information Obtained. The last two sections provide the clinician with a place to report information obtained from psychological testing (see below), relevant laboratory values (e.g., creatinine, blood urea nitrogen, phosphorus, potassium, albumin), and medications. These sections are not a part of the clinical interview but can be used to cue the clinician about what other relevant information should be obtained.
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The Administration of the SIRT
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The SIRT is a tool that facilitates both a comprehensive and efficient assessment of patients being evaluated for renal transplantation. Despite the structured nature of the instrument, it flows easily and allows for flexibility. General clinical expertise is required to conduct the interview, and knowledge of ESRD is necessary. No special equipment, tools, or manuals are needed. Although the SIRT is easily administered and can facilitate training, it is not a substitute for good clinical judgment, comprehensive knowledge about renal disease, and solid interviewing skills.
The SIRT was developed to facilitate a comprehensive assessment. Many of the items are multiple choice, Likert-type ratings, or use a checklist; a few items are open-ended. The structure of the questions is designed to guide the clinician and help the patient provide a focused response; it is not meant to abbreviate the interview. The SIRT should not be administered like a script, and if patients want to appropriately elaborate on a response, they should be encouraged. Clinicians can also gather more information where they deem appropriate. The administration of the SIRT usually takes between 60 and 90 minutes.
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The Boston Veterans Affairs (VA) Medical Center Protocol
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The SIRT was designed to provide the structure for a comprehensive clinical interview for renal transplant candidates, but its use is further enhanced by obtaining additional relevant clinical information. For example, data obtained from psychometrics and neuropsychological testing can be very useful. Below is a description of how the SIRT is used in the context of a complete psychiatric evaluation at a VA Medical Center renal transplant service in Boston.
Transplant evaluations at the Boston VA typically occur over a 5-day inpatient hospitalization (Monday to Friday). When patients first arrive, they are given a package of psychometric instruments that they are asked to complete. This package includes the Minnesota Multiphasic Personality Inventory (MMPI-2),27 the Beck Depression Inventory,28 the COPE,29 and the Multidimensional Health Locus of Control.30 These tests allow the clinician to obtain information about the patients' personality style, potential psychological risk factors, level of depression, and coping style.
Patients also have an appointment with a neuropsychologist to take a battery of cognitive tests. These tests include the Wide Range Achievement Test—Third Revision,31 Trail Making A&B,32 Digit Span and Comprehension from the Wechsler Adult Intelligence Scale—3,33 the California Verbal Learning Test,34 and Visual Reproductions from the Wechsler Memory Scale-Revised (WMS-R).35 This neuropsychological screening helps the clinician to identify cognitive impairment that could interfere with the patients' ability to comprehend or to remember information relevant to the transplant process. This screening also helps the clinician to detect impairment in the patients' judgment and problem-solving ability. These data not only provide information about the patients' suitability for transplant but also alert staff to potential learning barriers that should be addressed.
Finally, after the SIRT has been administered, testing has been completed, the chart has been reviewed, and information from treatment providers has been obtained, final ratings about the patients' psychiatric appropriateness for transplantation are made using the Psychosocial Assessment of Candidates for Transplantation (PACT).5 The PACT is an instrument that clinicians evaluating transplant candidates can use to make standardized ratings on a range of psychosocial dimensions that include social support, psychological health, lifestyle factors, and understanding of the transplant procedure. In addition, PACT includes a final global rating of the patients' overall appropriateness for transplantation.
Clinicians at the Boston VA have found that using the SIRT to evaluate transplant candidates ensures that they have systematically and carefully obtained the appropriate information that allows them to have confidence in their ratings on the PACT. We have used these ratings to examine the factors that appear to influence clinical decision making regarding one's appropriateness for transplantation.26 Patients who were identified as low-risk candidates (transplant candidacy with no contingencies) were found to have significantly greater psychological stability and adjustment, medical compliance, knowledge about transplantation, and a healthier lifestyle than high-risk candidates (transplant candidacy refused or contingent on behavioral changes). Interestingly, no differences were found between low-risk and high-risk candidates on either the MMPI-2 or Beck Depression Inventory. This finding highlights the importance of recognizing the limitations of any tool used when conducting a psychological assessment with renal transplant candidates. Although decision making in transplantation should not be based solely on psychological testing, it can provide useful clinical information that can be further explored in the interview. For example, although a high score on the Beck Depression Inventory may not be used to rule out a person for transplantation, the impact of depression on the candidate's ability to comply with a medical regimen would need to be explored.
All of the information gathered through chart review, the administration of the SIRT, and psychometric testing is used to write a well-synthesized, concise report about the patients' psychiatric appropriateness for transplantation. This information is also used to guide the clinicians' presentations at the interdisciplinary team meeting where decisions regarding the patients' appropriateness for transplantation are made. The surgeons and other team members appear to appreciate the comprehensive nature of these psychological evaluations. We present our cases by highlighting the salient psychological aspects of each case, and this process appears to have educated others about important psychological variables that impact transplantation. Because we are able to provide objective recommendations about behaviors that can impact outcome, our impressions are always sought out and our recommendations are seriously considered.
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Implications for Research
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The SIRT can be used as a valuable research tool as it provides a method for collecting information in a systematic and standardized manner across patients and sites. Furthermore, most of the responses are coded numerically while the instrument is being administered. Having information that is retrieved and coded in this systematic manner facilitates the easy entry of this information directly into a database.
Critical decisions regarding renal allocation should not be made in the absence of supporting empirical data, yet there are few prospective studies that look at psychological and behavioral variables that predict outcome. Some of the research that has been conducted in this area has highlighted the importance of using careful, empirically supported facts when engaging in renal allocation decision making. Having a structured interview, like the SIRT, can help to generate much-needed research to facilitate a clinician's ability to make good and ethical decisions in organ allocation.
It should be noted that this instrument was devised for the purpose of collecting interview data in a systematic manner and was not devised to measure a particular psychological construct. For this reason, no validation analyses were conducted.
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Conclusion
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Optimal assessment of pretransplant renal patients requires knowledge of psychiatric factors and compliance behaviors that impact outcome. In addition to good interviewing skills and a background in psychiatry, a clinician must also be knowledgeable about the renal medical regimen and behavioral factors that could impact compliance. In order to evaluate the patient as a prospective transplant candidate, it is important to conduct a comprehensive assessment of the patient's knowledge and behaviors relating to chronic renal insufficiency and potential transplantation.
At present, there is no standardized protocol to evaluate renal transplant candidates. The SIRT was developed by professionals experienced with this population to guide clinicians and to improve the standardization of the assessment process. Although the instrument is comprehensive, it is easy to administer, and allows for flexibility. The SIRT is neither costly nor cumbersome, and no manual or special tools are needed.
The SIRT is also a very useful tool for professionals in training or those who are less experienced with this population. The instrument serves as a guide for trainees who are conducting assessments by highlighting the important areas to investigate.
There are also tremendous ethical and legal implications associated with making decisions regarding organ allocation. In accordance with the Americans With Disabilities Act, it is important for clinicians to use their knowledge about behavior to enhance the lives and widen the treatment options of chronically ill patients in need of renal transplantation. Clinicians can do this by expanding their role beyond aiding in the determination of allocation of resources; they can also provide behavioral recommendations to help patients become more appropriate transplant candidates. By doing this, the focus shifts from ruling out candidates to rehabilitating patients who might otherwise be rejected from candidacy status. The data yielded by the SIRT help clinicians formulate behavioral recommendations for high-risk transplant candidates. High-risk transplant candidates can benefit from recommendations that will help them optimize their care and maximize their potential of being successfully transplanted.
There is currently a critical shortage of donated kidneys, and the amount of time that potential recipients wait for a transplant is continually growing longer. Consequently, it is simultaneously becoming increasingly more important and difficult to allocate kidneys to the most appropriate candidates. To make these decisions, it is important to ensure that the patient is not only medically fit to undergo transplantation but also psychologically appropriate. However, there is currently a relative dearth of empirical information about the psychological variables that best determine transplant outcome in terms of morbidity, mortality, and overall quality of life. Despite the lack of research, clinicians are making major decisions regarding patients' candidacy status and often use different information on which they base their decisions. Given this, it is critically important that a standardized assessment protocol be established so that objective data can be collected and investigated. The SIRT can facilitate the development of research protocols by providing the structure for a standardized database so that research can be conducted on enhancing psychiatric clinical decision making in renal organ allocation.
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This article has been cited by other articles:
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R. J. Leo, B. A. Smith, and D. L. Mori
Guidelines for Conducting a Psychiatric Evaluation of the Unrelated Kidney Donor
Psychosomatics,
December 1, 2003;
44(6):
452 - 460.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
