Psychiatric Assessment of Liver Transplant Candidates

The psychiatric assessment of the transplant candidate is a critical component of the transplant evaluation process. There is a relatively high degree of psychiatric morbidity in patients being considered for organ transplantation. However, active psychiatric illness is a modifiable risk factor. The first goal of the psychiatric assessment is to determine the risk for psychiatric complications that may compromise a patient’s ability to successfully navigate the complexities of transplantation. The second goal is to make recommendations to mitigate these risks. The transplant evaluation is optimally accomplished by a multidisciplinary team. Team members include psychologists, who perform neuropsychiatric testing and can provide counseling for the patient and family. Social workers assess social support, identify caregivers, and assist with financial and insurance needs. A chaplain can provide emotional support to patients and families. Chemical dependency specialists can help with recommendations regarding substance abuse issues. Transplant coordinators who have frequent contact with the patients and families can also offer important collateral history to the psychiatrist about the patient’s ability to interact effectively with the transplant team. The role of the transplant psychiatrist is to evaluate the patient with a view to diagnosis of psychiatric disorders, including substance abuse and neurocognitive impairment; to assess coping skills and adherence history; and to make treatment recommendations that can improve the patient’s chance of a good medical outcome.

Transplant teams are often confronted with ethical issues surrounding the allocation of organs because they are a scarce resource. They must balance doing what is best for the patient with what is best for all patients who need transplants. Psychiatric risk assessment is complex and multidimensional and demands a comprehensive approach ( Fig. 30-1 ). It is best accomplished by a dedicated transplant psychiatrist who works closely with the transplant team and is familiar with the gamut of pretransplant and posttransplant medical, surgical, and psychiatric issues in this special population.

The Role of the Transplant Psychiatrist

The transplant psychiatrist conducts an extensive clinical psychiatric interview ( Table 30-1 ) that encompasses past and present psychiatric history, including outpatient psychiatric treatment, inpatient psychiatric hospitalizations, suicidality, symptomatology, pharmacotherapy, and counseling. A history of depressive disorders, anxiety disorders, including posttraumatic stress disorder, and substance abuse, including drugs and alcohol as well as prescribed opioid medications, is common in patients presenting for liver transplantation. Pain disorders are among the many medical conditions common in this population as well. Cognitive impairment due to hepatic encephalopathy complicates the assessment of the patient presenting for liver transplantation. A family history of psychiatric disorders increases the patient’s risk for a psychiatric disorder. A history of nonadherence with medical recommendations alerts the psychiatrist to the potential for future nonadherence. Maladaptive coping skills are also a risk factor for a poor medical outcome ( Table 30-2 ).

TABLE 30-1

Transplantation Psychiatric Interview

Patient’s reaction to end-stage disease

Knowledge about transplantation

History of compliance

Acceptance of posttransplant medical regimen, including need for daily immunosuppressives, and medical follow-up

Family reaction to health

Psychiatric review of systems

Past psychiatric history

Family psychiatric history

Alcohol use history

Illicit substance history

Prescription drug use history

Nicotine use history

Developmental history

Mental status examination

TABLE 30-2

Behavioral Checklist

Noncompliance with follow-up appointments

Limited support system

Family conflict

Expressed hostility to transplant team

Idealizing or devaluing members of the transplant team

Expectation of “special treatment” (e.g., rescheduling appointments repeatedly for insignificant reasons)

Excessive concern with physical appearance

Rigid expectations regarding patient education, medical information (e.g., repeated requests for detailed information despite reasonable efforts at education)

Indifference to medical teaching/instructions

Contradictory history provided to different members of the transplant team

Engaging in high-risk behavior (altercations with police, little

concern about personal safety)

Switching transplant centers for unclear reasons

Marked ambivalence about transplantation

When the transplant psychiatrist elicits history that warrants further investigation, such as psychiatric diagnostic clarification or neurocognitive assessment, a neuropsychiatric evaluation with psychometric testing tools is recommended. Identification of maladaptive personality traits, occult psychiatric symptoms, and degree of cognitive impairment can guide further recommendations. However, these types of assessments are not sufficient for diagnosis and should be used to complement the clinical medical evaluation performed by the transplant psychiatrist. Transplant-specific scales have been created to help assist transplant teams in identifying areas of concern. The Transplant Evaluation Rating Scale and the Psychosocial Assessment of Candidates for Transplant scale rate the patients on family support and availability, past psychiatric history, coping, substance use, adherence history, and knowledge about transplantation. However, the predictive validity of these scales is unclear.

Historically there has been variability across transplant centers, as well as between heart, liver, and kidney programs, regarding certain psychiatric selection criteria. Mental retardation, active schizophrenia, criminality, and methadone maintenance therapy have been and continue to be exclusion criteria in some cases. However, with the advancement of medical knowledge and improved treatment options for patients, as well as the ethical imperative to consider each case on an individual basis, the boundaries of what is considered acceptable risk are being propelled to new frontiers.

Special Issues

Adapting to the Waiting Period

The stress of the waiting period with the associated physical symptoms that impair quality of life (QOL) can be difficult for the patient. Muscle cramps and pruritus have been found to impair QOL significantly, as have encephalopathy, sleep disorders, and refractory ascites. Sleep disorders of clinical significance occur in approximately 50% of cirrhotic patients. Minimal hepatic encephalopathy can affect cognition and behavior. Depression is also not uncommon. Patients may have fears of death and worry about family members and impending surgery. Patients will often struggle to continue working despite increasing problems with concentration and fatigue. Moreover, fear of losing insurance coverage can cause distress. Spouses will often need to maintain insurance coverage if their insurance is the primary one for the patient. This may make it difficult for spouses to accompany patients to appointments. Some studies report that spouses can experience even higher levels of stress than patients do, both before and after transplant. The spouse and other family members may benefit from meeting with the transplant team and participating in support groups. Many transplant centers offer support groups for patients and their families, to provide information and foster development of skills to cope with the challenges of the transplant process. Topics discussed include medication, side effects, the healing process, and financial issues. Patient education may be impeded by language barriers, learning disabilities, or encephalopathy. In these circumstances an interpreter is recommended. Patients are more likely to remember if they understand the information and are more likely to be adherent if their preferences are considered. The doctor-patient relationship is also an important factor in communicating information to patients.

Mood Disorders

Mood disorders occur frequently in patients awaiting transplantation, and 47% of patients have been reported to experience depressive symptoms, which were associated with a history of alcohol abuse, interpersonal sensitivity, and being single. The presence of depression before transplantation may not predict posttransplantation nonadherence but warrants attention because of the detrimental effects on QOL and ability to manage complex medical regimens. Typically patients experiencing symptoms of depression (which may include reports of irritability) can be started on low doses of serotonin reuptake inhibitors and gradually titrated upward to address mood symptoms in the pretransplant period. Although concerns about increased gastrointestinal bleeding have been reported, no consensus exists on this risk because of conflicting reports about the frequency of this occurrence.

Following transplantation, depression occurs relatively frequently and has been reported to occur in up to 33% to 63% of patients. It has been reported to adversely affect QOL and increase mortality. Another study reported that pretransplantation depression predicted posttransplantation depression but not graft rejection, graft failure, infection, or increased mortality. ²⁶ Patients with hepatitis C are more likely to report depression symptoms following transplantation. Antidepressants are well tolerated following transplantation, and citalopram, sertraline, and venlafaxine can be used at typical dosage ranges if patients have returned to good hepatic function and generally have few interactions with immunosuppressive medications. Mirtazapine be can be a helpful medication for patients with weight loss and poor sleep because of appetite stimulating and sedating side effects. Mirtazapine is partially renally excreted, so dosage may need to be adjusted for patients with decreased renal function. Debilitated patients may be undergoing treatment for hepatitis C with interferon (IFN)-α, which is associated with fatigue, cognitive difficulties, neurovegetative symptoms, and suicidal ideation, and may do well with mirtazapine, although they should be monitored for blood dyscrasias.

Anxiety has been reported in up to 19% of pretransplant patients. Patients with autoimmune conditions or those who were unemployed reported anxiety more frequently and alcoholic patients less frequently. Caregivers of cirrhotic patients reported higher rates of anxiety compared to the cirrhotic patients. Patients with fulminant hepatic failure tended to report higher rates of posttransplantation anxiety. Following transplant, patients with anxiety reported greater depression, financial problems, and negative social and emotional functioning. Patients with hepatitis C reported higher degrees of anxiety. Psychosocial stress may affect progression of hepatitis C because of effects on tumor necrosis factor, interleukin (IL)-1 and IL-6. Following transplantation, patients usually can be managed with serotonin reuptake inhibitors for persistent anxiety and brief exposure to benzodiazepines. Before transplantation, benzodiazepines can exacerbate symptoms of hepatic encephalopathy.

Patients with bipolar disorder have been transplanted and may do well if they have had long-standing stability and careful monitoring is available for detection of active symptoms of mood instability. Lithium is primarily renally excreted and can be used in end-stage liver disease, but monitoring of the patient's fluid status is important because of the risk for toxic levels with volume depletion. Ongoing assessment following transplantation is important because of the risk for manic symptoms emerging while the patient is on higher-dose steroids following transplant. Psychiatric consultation to assist in management of these patients is recommended.

Patients benefit from nonpharmacological strategies such as support groups to help cope with the fear of the unknown, to share common experiences, and to enhance problem-solving strategies. Encouraging exercise, maintaining social connections, ongoing participation in spiritual activities, and encouraging an optimistic framework may help decrease the risk for emerging psychiatric symptoms in the setting of medical illness. Herbal remedies should be avoided because of the possible adverse effects on the liver.

Alcohol Abuse

Alcoholic cirrhosis is the second most common diagnosis for patients receiving liver transplantation and accounts for 20% of all liver transplants that were performed between 1988 and 2009. Patients transplanted for alcoholic liver disease have reasonable QOL following transplantation, although some reports of decreased physical QOL have been reported with increased reports of pain and physical deficits. Survival following liver transplantation is comparable to patients with nonalcoholic liver disease and better than patients with hepatitis C.

Risks for relapse include abstinence less than 3 months, nonacceptance of the diagnosis of alcoholism, alcohol dependence diagnosis versus abuse diagnosis, family history of alcohol dependence, and use of other substances ( Table 30-3 ). Relapse rates as high as 90% have been reported, but in detailed, prospective research different trajectories of alcohol use have been noted, with 54% having no use and of those who resumed drinking, the majority drank at low levels on occasion. The researchers noted that others had patterns of moderate use that diminished over time, later-onset moderate use that increased over time, and early-onset, heavy use that increased. Higher mortality was noted in the moderate and heavy relapsing groups.

TABLE 30-3

Risks for Relapse in Alcoholic Liver Transplantation Patients

Polydrug dependence

Lack of stable social support

Lack of insight about diagnosis

Personality disorder

Past inability to maintain abstinence (previous failed treatment attempts)

Spouse/partner continues to use alcohol/substances

The role of treatment for patients has been studied, and patients randomly assigned to motivation enhancement treatment versus treatment as usual had lower rates of relapse while on the waiting list, and surprisingly 25% of the subjects relapsed after randomization in the study while on the waiting list. Most centers recommend either attendance at Alcoholics Anonymous, participation in counseling, or formal treatment in an addictions treatment program, but no standard exists for all centers. In 1997 a consensus conference of the American Association for the Study of Liver Diseases and the American Society of Transplantation recommended abstinence from alcohol of at least 6 months, but this is not supported by research that would suggest that this length of time is a significant cutoff point predicting abstinence.

In the past, patients with serious alcoholic hepatitis with no response to medical therapy were not considered for transplantation. However, a multicenter study investigating the role of transplantation for severe alcoholic hepatitis suggested that patients with strong family support who made a commitment to abstinence and had no other severe coexisting conditions had better survival than those who were not transplanted (77% versus 23%).

Tobacco

Patients evaluated for liver transplantation have a higher lifetime history of tobacco use than the general population. A substantial number of patients evaluated for transplantation are active smokers. Obtaining a tobacco use history is critical for two reasons. First, nicotine dependence has been found to be highly comorbid with other psychiatric disorders and can herald other areas of psychiatric history that require deeper exploration. Second, studies have demonstrated that smoking is a significant cause of increased morbidity and mortality in liver transplant patients.

Smoking and Psychiatric Morbidity

Tobacco use is highly comorbid with psychiatric disorders. In a representative U.S. sample, individuals who had a lifetime history of two or more psychiatric diagnoses had higher rates of smoking and smoked more cigarettes per day. Heavier smoking may be an indication of nicotine dependence. Nicotine dependence, defined as an addiction to nicotine, is associated with other axis I psychiatric disorders, including substance use disorders. Nicotine-dependent individuals have higher rates of alcohol, marijuana, and cocaine dependence. Nicotine dependence is also associated with depression and anxiety disorders. Mood disorders associated with nicotine dependence include major depression, dysthymia, and bipolar disorder. Among the anxiety disorders correlated with nicotine dependence are posttraumatic stress disorder, panic disorder, and social phobia. Personality disorders have also been associated with nicotine dependence. Authors have speculated that patients may be self-medicating psychiatric symptoms with nicotine, which produces strong positive reinforcing effects through the release of dopamine and serotonin.

Smoking Increases Morbidity in Liver Transplant Recipients

Smoking has health implications for liver transplant candidates. A history of tobacco use is associated with persistent health risks after liver transplantation. Smoking at the time of evaluation for liver transplantation is correlated with increased morbidity and all-cause mortality. In particular, a history of smoking in liver transplant patients is associated with increased rates of vascular complications, including hepatic artery thrombosis. In patients who are abstinent from tobacco for 2 years before liver transplantation, the rate of vascular complications is reduced by 58%. Both active and former smokers at the time of liver transplantation are also at increased risk for biliary complications after transplantation. Smoking is also a risk factor for the development of de novo malignancies after liver transplantation. A history of smoking before liver transplantation and smoking after liver transplantation are associated with de novo malignancies. Smoking may also increase the risk for infection in liver transplant patients. Tobacco is heavily contaminated with fungal spores, including Aspergillus fumigatus, Fusarium, Acremonium, Rhizopus, and Scedosporium, and may increase the patient’s risk for infectious disease, especially in the setting of immunosuppression.

Smoking Exacerbates and Accelerates Liver Disease

Several recent studies demonstrate an association between smoking and advanced fibrosis in chronic liver diseases, including primary biliary cirrhosis, nonalcoholic fatty liver disease, and chronic hepatitis C. One study demonstrated a clear hepatotoxic effect on the severity of histological activity in patients with chronic hepatitis C, particularly in patients smoking more than 15 cigarettes per day. Moreover, smoking is associated with the development of hepatocellular carcinoma. There is also an increased risk for hepatocellular carcinoma in patients with viral hepatitis and simultaneous exposure to alcohol and tobacco, suggesting synergism. Recent evidence also indicates that smoking increases the risk for recurrent viral hepatitis after liver transplantation.

Alcohol Use Disorders in Smokers

Approximately 90% of patients with alcohol abuse also smoke tobacco. A diagnosis of alcohol dependence elevates the risk for nicotine dependence. The relationship between alcohol use disorders and nicotine dependence is particularly relevant in the liver transplant population, in which a large percentage of patients are transplanted for alcoholic liver disease. Smoking is extremely common in patients with alcoholic liver disease. Most liver transplant patients with alcohol abuse or dependence are also nicotine dependent. One study found that liver transplant recipients with alcoholic liver disease had an average smoking history of 10 more pack-years than patients with nonalcoholic liver disease. Several studies have shown increased risk for cancers in patients transplanted for alcoholic liver disease with a history of tobacco use. Smoking has also been implicated in increased risk for cardiovascular events and increased rates of de novo cancers in patients with recidivism to alcohol after liver transplantation. Although tobacco and alcohol each exert independent effects in the pathogenesis of these cancers, the potential for synergy has also been suggested.

A high percentage of patients transplanted for alcoholic liver disease resume tobacco use after transplantation. One study revealed that 61% resumed tobacco use within 1 year after transplantation. Of those who resumed smoking, most resumed within 3 months of liver transplantation, were smoking daily, increased their consumption over time, and quickly became nicotine dependent. Patients who relapsed to alcohol after transplantation had increased tobacco consumption. Several other studies also demonstrate an association between alcohol recidivism and tobacco use after liver transplantation. Given the comorbidity of alcohol and tobacco use, recidivism to tobacco may be a risk factor for relapse to alcohol after liver transplantation.

Given that tobacco use is associated with poorer outcome after transplantation, it has been argued that explicit advice to discontinue smoking, as well as referral to smoking cessation programs, should be a condition of listing. In general, liver transplant patients are in need of greater access to tobacco cessation programs, particularly those patients with other substance abuse issues. However, referral to a community tobacco cessation program may not be sufficient. Tobacco use is a chronic disorder that requires a structured, comprehensive approach. Several studies suggest that liver transplant centers should develop programs to address nicotine addiction that focus on pretransplant cessation and posttransplant abstinence. Moreover, the intervention programs should target not only active user of tobacco but also former users, and participation should be long term.

It is important to note that individuals with psychiatric conditions are less successful at smoking cessation. Therefore more-comprehensive services may be necessary to assist patients with comorbid psychiatric illness and nicotine dependence with smoking cessation. Incorporation of mental health treatment into tobacco cessation programs may increase the effectiveness of these programs.

Smoking as a Contraindication to Transplantation

Although authors agree that smoking cessation should be encouraged in patients undergoing liver transplantation, requiring cessation of smoking before liver transplantation remains controversial. Only a small number of transplant centers consider smoking an absolute contraindication to liver transplantation. Several studies suggest that tobacco cessation may improve long-term outcomes in transplant patients. The accumulating evidence that indicates smoking is deleterious to liver transplant patients has prompted some authors to recommend that liver transplant programs may do well to initiate smoking cessation policies similar to those for heart and lung transplant listing, making smoking cessation an absolute requirement for liver transplantation. Liver transplant programs may need to consider a requirement of 6 months’ abstinence for tobacco, as is done with alcohol and other substances of abuse. A recent paper addressed the question of whether it is ethical to deny a patient for liver transplantation on the basis of smoking. Given the substantial literature that underscores the morbidity and mortality in liver transplant patients who smoke, the author suggested that it is both ethically and medically reasonable to use active smoking as a contraindication to transplantation.

Marijuana

There is no standard United Network for Organ Sharing (UNOS) policy regarding marijuana smoking in patients being considered for liver transplantation. However, many transplant centers discourage the use of marijuana in liver transplant candidates and require a period of abstinence before transplantation in active users of marijuana. A recent survey indicates that 70% of U.S. transplant centers feel marijuana use is an absolute contraindication to liver transplantation.

Patients presenting for liver transplantation may state that they are using medical marijuana, obtained through a prescription, for nausea, anorexia, or pain, yet there remains concern over the legitimacy of medical marijuana use. Moreover, whether it is used for medicinal versus recreational purposes may be irrelevant with respect to liver transplantation. First, marijuana is a substance with abuse liability. Its use is often comorbid with other substance abuse, including tobacco, benzodiazepines, opioids, amphetamine, cocaine, and barbiturates. Marijuana has significant detrimental effects on motor and cognitive skills, attention, performance, and memory, which may affect the patient’s ability to comply with a complicated posttransplantation regimen. This could result in nonadherence with medications. Marijuana use is also associated with respiratory symptoms, including dyspnea and cough, as well as cerebrovascular complications, including stroke. Furthermore, several studies have demonstrated that marijuana use is a risk factor for fibrosis, steatosis, and hepatocellular carcinoma in patients with chronic hepatitis C. Marijuana smoking in transplant patients has also been associated with invasive aspergillosis, which carries a risk for severe complications.

Abstinence from marijuana use is not necessarily a requirement for listing in all liver transplant programs. However, concerns of comorbid psychiatric disorders, including substance abuse, as well as pain issues, and the medical morbidity associated with marijuana, including potentially lethal complications from infection, suggest that cessation of marijuana use may be advisable. Patients actively smoking marijuana at the time of transplant evaluation may benefit from referral to a 12-step program. The team may wish to obtain random urine toxicological screens to monitor abstinence. Results of a urine toxicological screen may remain positive for several months after discontinuation of marijuana. Any initial screen that is positive for cannabinoids should be followed up with quantifications to ensure ongoing abstinence.

Personality Disorders

Personality disorders are defined by an enduring pattern of maladaptive traits, consisting of experiences and behaviors affecting the cognitive and affective realms, interpersonal functioning, or impulse control, which lead to distress or impairment. Personality disorders are highly comorbid with substance abuse and mood disorders. The presence of a severe personality disorder is common among patients with severe alcohol-related liver disease. Antisocial personality disorder is common in the liver transplant population. Antisocial personality disorder is characterized by persistent social rule-breaking, deceitfulness, and offending behavior, with lack of remorse. It is associated with criminality, unemployment, homelessness, interpersonal difficulties, and substance abuse.

Borderline personality disorder is the most prevalent personality disorder in the general psychiatric population. Patients with borderline personality disorder may present to the hospital after self-harming and may come to the attention of the liver transplant team in the setting of acetaminophen overdose. Borderline personality disorder is characterized by affective dysregulation, poor impulse control, disturbed interpersonal relationships, and unstable self-image. Hallmarks of the disorder include emotional lability and self-injurious behavior. These patients have chronic suicidal tendencies. The disorder is highly comorbid with mood and anxiety disorders, substance abuse, and eating disorders. Although the long-term course of borderline personality disorder is characterized by symptom remission, impairment in social functioning can be severe and persistent.

Transplant patients must cope with challenges, including the extensive evaluation process, waiting for a donor organ and living with increasing disability, the trauma of surgery, recovery, posttransplant maintenance, and overall adjustment to daily life after transplantation. The presence of a personality disorder can have an impact on posttransplant behavior, management, adherence, and patient satisfaction. Associated symptoms of personality disorders can surface or become exacerbated when a patient is under stress. These patients have ineffective coping skills, which may lead to the inability to navigate the complexities and rigors of transplantation.

Several studies demonstrate that personality disorders are significantly associated with nonadherence after solid organ transplantation. Nonadherence in transplant patients with personality disorders is correlated with poor outcomes. Comorbid substance abuse in patients with personality disorders may increase the risk for nonadherence.

Personality disorders are also associated with poorer QOL after transplantation. Patients with antisocial personality disorder transplanted for alcoholic liver disease endorsed more physical symptoms and functional impairment related to pain and reported increased rates of poorer emotional well-being after transplantation. Patients with personality disorders have disturbed interpersonal relationships, which may decrease the likelihood of a strong social support system for the patient. They can exhibit behavioral problems after transplantation reflective of these social and relational difficulties, which may have an impact on the ability of the medical team to maintain a therapeutic alliance with the patient. Behavioral problems may lead to the patient being labeled as “difficult,” necessitating increased effort to manage the patient and resulting in a disproportionate amount of time and attention spent on the patient. Patients with personality disorders may devalue members of the medical team, thereby engendering negative feelings toward the patient.

It has been suggested that the presence of a personality disorder should not be an absolute contraindication to transplantation, but rather should pose the opportunity for treatment recommendations that may mitigate the posttransplantation risks. Long-term therapy, before and after transplant is recommended. Pharmacological intervention may also be warranted. Identifying a strong social support network is critical. If liver transplantation is not urgent, the waiting time can be used as an indicator of the severity of the personality disorder. Adherence difficulties and interpersonal difficulties with family or team members should be monitored. However, in the setting of acute liver failure, obtaining collateral history from the family may shed light on the patient’s potential to work effectively with the transplant team. The transplant team may need to invoke innovative interventions in the posttransplant period to enhance adherence and optimize outcomes.

Schizophrenia

A 1993 survey of U.S. transplant centers revealed that active schizophrenia was considered an absolute contraindication to liver transplantation in 67% of liver transplant programs. Although controlled schizophrenia was considered a relative contraindication in 65% of programs, it was still an absolute contraindication in 15% of programs.

Schizophrenia is a chronic illness that puts patients at risk for increased morbidity and mortality. The several subtypes of schizophrenia carry different prognoses. In the paranoid subtype, delusions and auditory hallucinations are prominent, but it is associated with greater preservation of cognitive functioning throughout life. In contrast, the disorganized subtype is characterized by disorganized speech and behavior with relative absence of hallucinations and delusions. This subtype is associated with poor premorbid and overall functioning and significant cognitive impairment. The long-term prognosis for this subtype is poor compared to other subtypes. The “negative” symptoms of schizophrenia contribute to poor functionality and are the primary reason patients with schizophrenia are unable to live independently, maintain employment, establish relationships, and cope with quotidian social situations. Negative symptoms are also related to the cognitive impairment seen in these patients. However, patients with negative symptoms are more compliant with immunosuppressants than patients with the “positive” symptoms of paranoia, auditory hallucinations, and delusions. Patients with psychotic symptoms within the year before transplantation are at risk for suicide attempts. A history of noncompliance before transplantation and living alone or being homeless are associated with immunosuppressant nonadherence in schizophrenic patients.

There are few published data on organ transplantation in patients with psychotic illnesses such as schizophrenia. However, case reports of solid organ transplantation in schizophrenic patients indicate that despite the challenges, these patients can have successful outcomes after transplantation. ^∗

∗ References .

Some protective factors have been identified as contributing to good outcomes after transplantation in this population. Expert psychiatric management may facilitate the patient's posttransplant course. It is important to note that in the pretransplant and immediate posttransplant period, increasing the intensity of psychiatric treatment may be warranted and may improve adherence.

Living alone is correlated with nonadherence with immunosuppressant medications in schizophrenic patients. Strong family support can be a protective factor. Involved family members who actively participate in the patient’s care can have a positive influence on the patient’s outcome. Family members should be particularly watchful for psychiatric symptoms that herald decompensation and can affect adherence. Patient participation in community aftercare programs has been shown to improve outcomes in schizophrenia. One study reported that strong medical staff support and attendance in a psychiatric partial hospitalization program was effective in improving adherence in a schizophrenic patient who underwent transplantation. If there is time before transplantation, developing a longitudinal relationship with the transplant team, which allows for therapeutic alliance, may also strengthen the chance for a good outcome.

Special Considerations in the Transplant Patient With Schizophrenia

Patients with schizophrenia have a higher pain threshold and may not complain of pain or discomfort until severe. Medical illness may not be detected until a later stage. Early detection and workup of medical symptoms is imperative after transplantation, because organ rejection could be a complication. Therefore these patients need particularly close medical follow-up from both family and medical personnel.

Patients with schizophrenia may experience symptoms in the intensive care unit after transplantation, including agitation, delusions, or paranoia. This may be in part due to their underlying psychiatric diathesis but may also be due to medical factors such as delirium. There is some question as to whether steroids can precipitate psychosis in patients with psychotic illnesses. Several early papers report that patients with psychotic illness are no more susceptible to the neuropsychiatric effects of steroids than patients without psychotic illness. However, a 2002 survey of psychotic symptoms in patients who underwent transplantation indicates that there may be valid concerns regarding steroid exacerbation of psychosis in schizophrenia. The standard treatment of delirium suffices to control this complication if it occurs.

Ethical and Legal Issues

In a landmark paper, Orentlicher outlined the legal considerations of organ transplantation in patients with schizophrenia. He argued that because schizophrenia is a disability, denying organ transplantation to schizophrenic patients on the basis of the disability violates the Americans with Disabilities Act (ADA). However, he noted that when allocating organs for transplantation, it is appropriate to take into consideration and assess whether the disability will compromise the patient’s ability to receive benefit from the transplant. If the patient’s schizophrenia is so severe that he or she would not be able to benefit from the transplant, denial of transplantation may be justified. Assessment of the schizophrenic patient must be performed on an individual basis, and reasonable steps taken to mitigate the effect of the disability on the patient’s ability to benefit from transplantation. Some patients with schizophrenia or other psychotic illnesses can do well after transplantation. Active psychiatric illness is a potentially modifiable risk factor. Even patients considered high risk may do well with intensive and expert management. Factors that may be protective are strong family support and social network, relative psychiatric stability before transplantation, and ongoing psychiatric treatment with pharmacological management of symptoms.

Acetaminophen Toxicity and Acute Liver Failure

Acetaminophen toxicity is the most common cause of acute liver failure in the United States.

Acute liver failure due to acetaminophen toxicity has a distinct course characterized by rapid clinical deterioration to multisystem organ failure and gross encephalopathy. In some cases the patient can be lucid before the onset of encephalopathy and able to provide a history. Often, however, the patient is already encephalopathic or intubated. and cannot be interviewed, which limits the ability to obtain a comprehensive psychiatric history. ^†

† References .

Although it is not optimal to obtain the history from family, friends, or roommates because they may not know the relevant history or may be reluctant to disclose it, sometimes it is the only option available.

Psychiatric Morbidity and Acetaminophen Toxicity

There is a high prevalence of psychiatric morbidity in patients with acetaminophen-induced hepatotoxicity. Acetaminophen overdose has been associated with mood disorders, including depression ; substance abuse, including alcohol abuse ; and chronic pain.

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