Emotional well-being of living kidney donors: findings from the RELIVE Study.

Following kidney donation, short-term quality of life outcomes compare favorably to US normative data but long-term effects on mood are not known. In the Renal and Lung Living Donors Evaluation Study (RELIVE), records from donations performed 1963-2005 were reviewed for depression and antidepressant use predonation. Postdonation, in a cross-sectional cohort design 2010-2012, donors completed the Patient Health Questionnaire (PHQ-9) depression screening instrument, the Life Orientation Test-Revised, 36-Item Short Form Health Survey and donation experience questions. Of 6909 eligible donors, 3470 were contacted and 2455 participated (71%). The percent with depressive symptoms (8%; PHQ-9>10) was similar to National Health and Nutrition Examination Survey participants (7%, p=0.30). Predonation psychiatric disorders were more common in unrelated than related donors (p=0.05). Postdonation predictors of depressive symptoms included nonwhite race OR=2.00, p=0.020), younger age at donation (OR=1.33 per 10 years, p=0.002), longer recovery time from donation (OR=1.74, p=0.0009), greater financial burden (OR=1.32, p=0.013) and feeling morally obligated to donate (OR=1.23, p=0.003). While cross-sectional prevalence of depression is comparable to population normative data, some factors identifiable around time of donation, including longer recovery, financial stressors, younger age and moral obligation to donate may identify donors more likely to develop future depression, providing an opportunity for intervention.

Health-related quality of life in kidney donors from the last five decades: results from the RELIVE study.

Live donation benefits recipients, but the long-term consequences for donors remain uncertain. Renal and Lung Living Donors Evaluation Study surveyed kidney donors (N = 2455; 61% women; mean age 58, aged 24-94; mean time from donation 17 years, range 5-48 years) using the Short Form-36 Health Survey (SF-36). The 95% confidence intervals for White and African-American donors included or exceeded SF-36 norms. Over 80% of donors reported average or above average health for their age and sex (p < 0.0001). Donors' age-sex adjusted physical component summary (PCS) scores declined by half a point each decade after donation (p = 0.0027); there was no decline in mental component summary (MCS) scores. White donors' PCS scores were three points higher (p = 0.0004) than non-Whites'; this difference remained constant over time. Nine percent of donors had impaired health (PCS or MCS score >1 SD below norm). Obesity, history of psychiatric difficulties and non-White race were risk factors for impaired physical health; history of psychiatric difficulties was a risk factor for impaired mental health. Education, older donation age and a first-degree relation to the recipient were protective factors. One percent reported that donation affected their health very negatively. Enhanced predonation evaluation and counseling may be warranted, along with ongoing monitoring for overweight donors.

Guidelines for the psychosocial evaluation of living unrelated kidney donors in the United States.

Under the auspices of the United Network for Organ Sharing, the American Society of Transplant Surgeons and the American Society of Transplantation, a meeting was convened on May 25, 2006, in Washington, DC, to develop guidelines for the psychosocial evaluation of prospective living kidney donors who have neither a biologic nor longstanding emotional relationship with the transplant candidate. These 'unrelated' donors are increasingly often identified by transplant candidates via the Internet, print media and other public appeals. The expansion of living donor kidney transplantation to include significant numbers of donors with little to no preexisting relationship to the candidate has caused concern in the medical community regarding such psychosocial factors as donor psychological status, motivation, knowledge about donation and the potential for undue pressure to donate under some circumstances. Therefore, experts in mental health; psychosocial, behavioral and transplant medicine; and medical ethics met to specify (a) characteristics of unrelated donors that increase their risk for, or serve as protective factors against, poor donor psychosocial outcomes, (b) basic principles underlying informed consent and evaluation processes pertinent to these donors and (c) the process and content of the donor psychosocial evaluation. The meeting deliberations resulted in the recommendations made in this report.

Psychosocial challenges in transplantation.

The authors review the psychosocial aspects of transplantation. They first review psychosocial risk factors that place transplant patients at higher risk for noncompliance and negative outcomes. They then discuss what assessments should be included in a pretransplantation psychosocial evaluation. Goals of the psychosocial evaluation include selection of candidates most likely to benefit from transplantation and identification of areas for psychosocial intervention, both before and after transplantation. The assessment should address the patient's premorbid psychiatric state, past adaptation to stressors, history of compliance with treatment, substance abuse history, and level of social support, including community and faith-based support systems. Results of psychometric assessments may be helpful when considered in conjunction with a clinical interview and other sources of information about the patient. It may also be helpful to use a screening tool developed specifically to evaluate psychosocial factors relevant to transplantation, such as the Psychological Assessment of Candidates for Transplantation (PACT) scale and the Transplantation Evaluation Rating Scale (TERS). The authors then review issues related to psychopharmacologic interventions in transplant patients, including the use of antidepressant medication pre- and post-transplant, strategies for avoiding delirium associated with immunosuppressive medications immediately post-transplantation, neuropsychiatric symptoms associated with interferon alpha therapy for hepatitis C, and interactions between over-the-counter and herbal agents (e.g., St. John's Wort) and immunosuppressive agents. Although limited research has been done on nonpharmacologic interventions, such as transplant support groups, it appears that certain types of group therapy, in particular, cognitive-behavioral groups that target specific risk factors such as depression, distress, and compliance, may also offer promising approaches for dealing with the problems of transplant patients. The authors then focus on two special situations that create particular problems for transplantation teams: liver transplantation in patients with alcoholic liver disease (ALD) and obesity in transplant patients. The authors conclude that the prognosis for patients with ALD who receive liver transplantation is similar to that of non-alcoholics and that alcoholism is not a contraindication for liver transplantation. However, careful preliminary psychosocial assessment is essential to review candidates for factors that are predictive of relapse, while close follow-up post-transplantation can help improve outcomes. It appears that obesity can increase the risk of negative outcomes in transplant patients, although there is currently no consensus on the use of obesity as an exclusion criteria. Interventions that take into account the special psychological and medical needs of transplant patients need to be developed for treating obesity both pre- and post-transplantation. Improved strategies for identifying high-risk patients and finding ways to intervene both pre- and post-transplantation can not only help lengthen transplant recipients' life spans, but also improve their adaptation to transplantation and lead to improved quality of life.

Major depression in medically ill patients.

Major depression is one of the most common psychiatric problems complicating the treatment and prognosis of patients with active medical illness. Recognizing and treating major depressive conditions in this population can often be challenging, even for the most seasoned clinicians. This article reviews the medical and neurologic conditions that have been associated with the high prevalence rates of major depression. Highlights of the evaluation process that help confirm this suspected diagnosis are addressed, and management issues are discussed. Brief reviews of supportive psychotherapeutic tools that the clinician may find helpful are included, as well as current advances in pharmacologic interventions.

Lung transplantation: selection of patients and analysis of outcome.

Lung transplantation is an important option for patients with respiratory failure and limited life expectancy. Herein we review the current indications for and outcome after lung transplantation. These results are compared with the natural history of various respiratory diseases, estimated from available databases. Candidates for lung transplantation are generally younger than 60 years of age, have a limited life expectancy because of end-stage lung disease, and have no other major organ dysfunction. Single lung transplantation is performed most commonly for emphysema, pulmonary fibrosis, and pulmonary hypertension. Survival after single lung transplantation is approximately 70% at 1 year, 60% at 2 years, and 40% at 3 years. The median duration of survival for patients with end-stage lung diseases ranges from approximately 2 to 6 years, with wide variation based on the diagnosis and severity of illness. Currently, prolongation of the average survival has not been clearly substantiated after lung transplantation. Further evaluation of outcomes, functional status, and quality of life after lung transplantation is necessary.

Pseudoseizures after epilepsy surgery.

Seizure surgery for medically intractable partial epilepsy in selected patients usually results in dramatically improved seizure control. However, the authors present six patients who, after surgery for refractory complex partial seizures, postoperatively experienced pseudoseizures (also known as nonepileptic seizures), confirmed with EEG monitoring. Three of these patients also had nonepileptic seizures preoperatively that coexisted with their partial epilepsy. Psychiatric assessment revealed that this patient group had several characteristics in common, which suggests that preoperative psychiatric consultation may help identify those patients at risk for developing nonepileptic seizures. Treatment strategies with anticonvulsant medications and behavioral therapy are reviewed.