Depression After Lung Transplantation: Causes and Treatment

Elements of Post-Transplant Recovery in Lung Transplant Recipients: A Scoping Review

To clarify and refine the specific elements of post-transplant recovery in lung transplant recipients, we explored the four dimensions of recovery: physiological, psychological, social, and habitual. This study is a scoping review. Two authors conducted a comprehensive electronic literature search to identify studies published from the establishment of the database to August 2022. Deductive coding was utilized to identify and categorize elements using a predefined list of the four components (physiological, psychological, social, and habitual recovery) based on the framework of post-transplant recovery proposed by Lundmark et al. Inductive coding was applied for concepts requiring further classification. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guideline. Systematic searching identified 8,616 potential records, of which 51 studies met the inclusion criteria. Ten subdimensions and their corresponding elements were identified and categorized into four dimensions of recovery following lung transplantation. The subdimensions included physiological recovery (including symptom experience, complications, physical function, and energy reserve), psychological recovery (encompassing affective distress, psychological adaptation, and transition from illness to health), social recovery (involving family adaptation and social adaptation), and habit recovery (focusing on health behavior).

Anxiety and Somatoform Syndromes Predict Transplant-Focused Internet Use in the Course of an Organ Transplantation

Background: e-Health interventions are increasing in the field of organ transplantations; however, the literature lacks evidence regarding needs, attitudes, and preferences of organ recipients and donors during the course of an organ transplantation. Methods: In a cross-sectional study, 70 subjects were assessed using self-rated and validated questionnaires, such as the PRIME MD Patient Health Questionnaire (PHQ-D) and the Essen Resource Inventory (ERI). Group differences and a multiple linear regression were also applied. Results: Organ recipients had significantly higher scores for depression (U = 245.00, z = -2.65, p = 0.008, Cohen's d = 0.32), somatoform (U = 224.50, z = -2.99, p = 0.003, Cohen's d = 0.37), and stress syndromes (U = 266.00, z = -2.25, p = 0.008, Cohen's d = 0.27). They also named the internet and apps as resources to find information regarding organ transplants (U = 177.50, z = -2.07, p = 0.017, Cohen's d = 0.28; Z = -2.308, p = 0.021) and preferred to use apps to monitor the physical condition (Z = -2.12, p = 0.034) significantly more than organ donors. Anxiety and somatoform syndromes were significant predictors to search for information regarding the transplant process (F[6,38] = 3.98, p < 0.001; R2 = 0.386). Conclusions: e-Health interventions are promising in accompanying the course of an organ transplant for patients to be informed and educated. Predominantly, potential organ recipients might benefit from apps to record physical parameters. However, anxiety syndromes might hinder patients from searching for information about the transplant process, while somatoform syndromes might enable patients who are searching for such information.

Depressive symptoms in lung transplant recipients: trajectory and association with mortality and allograft dysfunction

OBJECTIVE

Most studies observing an association between depressive symptoms following lung transplantation and mortality are limited to depressive symptom measurement at a single time point, unrelated to allograft function. We aimed to test the association of depressive symptoms over multiple assessments with allograft dysfunction and with mortality.

METHODS

We assessed depressive symptoms before and serially up to 3 years after lung transplantation in lung transplant recipients. We quantified depressive symptoms with the Geriatric Depression Scale (GDS; range 0-15; minimally important difference (MID): 2). We quantified changes in GDS using linear mixed effects models and tested the association with mortality using Cox proportional hazards models with GDS as a time-dependent predictor. To determine if worsening in GDS preceded declines in lung function, we tested the association of GDS as a time-dependent predictor with the lagged outcome of FEV₁ at the following study visit.

RESULTS

Among 266 participants, depressive symptoms improved early after transplantation. Worsening in post-transplant GDS by the MID was associated with mortality (HR 1.25, 95% CI 1.05 to 1.50), and in lagged outcome analyses with decreased per cent predicted FEV₁ (Δ, -1.62%, 95% CI -2.49 to -0.76). Visual analyses of temporal changes in GDS demonstrated that worsening depressive symptoms could precede chronic lung allograft dysfunction.

CONCLUSIONS

Depressive symptoms generally improve after lung transplantation. When they worsen, however, there is an association with declines in lung function and mortality. Depression is one of the few, potentially modifiable, risk factors for chronic lung allograft dysfunction and death.

Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients

OBJECTIVE

Posttransplant depression has been linked to increased risk for adverse outcomes in lung transplant patients. Maintaining target serum immunosuppressant levels is also essential for optimal lung transplant clinical outcome and may be a crucial predictor of outcomes. Because depression could affect medication nonadherence, resulting in out-of-range immunosuppressant levels, we examined the relationship between posttransplant depression, immunosuppressant medication trough level variability, indexed by out-of-range values on clinical outcomes and coefficient of variability, and clinical outcomes.

METHOD

A consecutive series of 236 lung transplant recipients completed the Center for Epidemiological Studies-Depression two-month posttransplant. Immunosuppressant trough levels (i.e., tacrolimus or cyclosporine) within the range of individualized immunosuppressant targets were obtained at three-, six-, nine-month follow-up clinic visits. Clinical outcomes including hospitalizations and mortality were obtained from medical records.

RESULTS

Fourteen percent of patients were classified as depressed (Center for Epidemiological Studies-Depression ≥16), 144 (61%) of patients had at least 25% out-of-range immunosuppressant values, and the average coefficient of variability was 36%. Over a median of 2.6 years (interquartile range = 1.2), 32 participants died (14%) and 144 (61%) had at least one unplanned, transplant-related hospitalization. Both depression (hazard ratio = 1.45 (1.19, 1.76), p < . 01) and immunosuppressant variation (immunosuppressant out-of-range: hazard ratio = 1.41 (1.10, 1.81), p < .01) independently predicted more frequent hospitalizations and higher mortality.

CONCLUSIONS

Early posttransplant depression was associated with significantly worse clinical outcomes. While immunosuppressant level variability is also related to adverse outcomes, such variability does not account for increased risk observed with depression.

Remote Therapy to Improve Outcomes in Lung Transplant Recipients: Design of the INSPIRE-III Randomized Clinical Trial

BACKGROUND

Impaired functional capacity and emotional distress are associated with lower quality of life (QoL) and worse clinical outcomes in post lung transplant patients. Strategies to increase physical activity and reduce distress are needed.

METHODS

The Investigational Study of Psychological Interventions in Recipients of Lung Transplant-III study is a single site, parallel group randomized clinical trial in which 150 lung transplant recipients will be randomly assigned to 3 months of telephone-delivered coping skills training combined with aerobic exercise (CSTEX) or to a Standard of Care plus Education control group. The primary endpoints are a global measure of distress and distance walked on the 6-Minute Walk Test. Secondary outcomes include measures of transplant-specific QoL, frailty, health behaviors, and chronic lung allograft dysfunction-free survival.

RESULTS

Participants will be evaluated at baseline, at the conclusion of 3 months of weekly treatment, at 1-year follow-up, and followed annually thereafter for clinical events for up to 4 years (median = 2 y). We also will determine whether functional capacity, distress, and health behaviors (eg, physical activity, medication adherence, and volume of air forcefully exhaled in 1 second (FEV1), mediate the effects of the CSTEX intervention on clinical outcomes.

CONCLUSIONS

Should the CSTEX intervention result in better outcomes compared with the standard of care plus post-transplant education, the remotely delivered CSTEX intervention can be made available to all lung transplant recipients as a way of enhancing their QoL and improving clinical outcomes.

Psychological profile and disease-coping strategies of patients on the waiting list for liver transplantation

AIM

To determine the psychological characteristics of patients on the liver transplant waiting list; to analye the implications of the patient's psychological profile on coping with the disease.

MATERIAL AND METHODS

Study population: patients on the liver transplant waiting list. Psychological-profile: Socio-personal history; Mini Mental State Examination; Brief-Symptom Inventory of psychopathological problems; International Neuropsychiatric Interview; Family APGAR questionnaire; Social Support Questionnaire. Coping with the disease: A questionnaire about mental adaptation to the disease. Patients were recruited for the study at the time when they were included on the waiting list.

RESULTS

The patients (n=112) had the following characteristics: 68% of the patients had symptoms of emotional psychopathology, with 48% being of a depressive, anxious and obsessive-compulsive type, respectively. In terms of social and family support, 27% had the perception of being in a dysfunctional family (slight-23%; serious-4%). What is more, according to the Global Support Index, 21% had non-functional social and family support. Coping with the disease: 8% were well-adapted to the disease, the remaining 92% were poorly adapted; of which, 79% had a weaker fighting spirit, 51% expressed anxiety and concern about coping with the disease, 34% found they resorted to fatalism, 29% were in denial and 27% felt helpless.

CONCLUSIONS

Once liver patients are included on the transplant waiting list, they poorly adapt to the disease, with important emotional implications that result in psychological alterations.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Depression and Anxiety as Risk Factors for Morbidity and Mortality After Organ Transplantation: A Systematic Review and Meta-Analysis

BACKGROUND

Depression and anxiety are common mental health problems in transplant populations. There is mixed evidence concerning whether they increase morbidity and mortality risks after transplantation. If such associations exist, additional risk reduction strategies may be needed.

METHODS

Four bibliographic databases were searched from 1981 through September 2014 for studies prospectively examining whether depression or anxiety (determined with diagnostic evaluations or standardized symptom scales) affected risk for posttransplant mortality, graft loss, acute graft rejection, chronic rejection, cancer, infection, and rehospitalization.

RESULTS

Twenty-seven studies (10 heart, total n = 1738; 6 liver, n = 1063; 5 kidney, n = 49515; 4 lung, n = 584; 1 pancreas, n = 80; 1 mixed recipient sample, n = 205) were identified. In each, depression and/or anxiety were typically measured before or early after transplantation. Follow-up for outcomes was a median of 5.8 years (range, 0.50-18.0). Depression increased the relative risk (RR) of mortality by 65% (RR, 1.65; 95% confidence interval [95% CI], 1.34-2.05; 20 studies). Meta-regression indicated that risk was stronger in studies that did (vs did not) control for potential confounders (P = .032). Risk was unaffected by type of transplant or other study characteristics. Depression increased death-censored graft loss risk (RR, 1.65; 95% CI, 1.21-2.26, 3 studies). Depression was not associated with other morbidities (each morbidity was assessed in 1-4 studies). Anxiety did not significantly increase mortality risk (RR, 1.39; 95% CI, 0.85-2.27, 6 studies) or morbidity risks (assessed in single studies).

CONCLUSIONS

Depression increases risk for posttransplant mortality. Few studies considered morbidities; the depression-graft loss association suggests that linkages with morbidities deserve greater attention. Depression screening and treatment may be warranted, although whether these activities would reduce posttransplant mortality requires study.

Outcomes of lung transplant candidates referred for co-management by palliative care: A retrospective case series

BACKGROUND

Lung transplant candidates experience important symptoms, but they are rarely referred for palliative care consultation until they are deemed ineligible for transplant. Our lung transplant service has a high rate of palliative care referral for patients awaiting transplant.

AIM

We reviewed the characteristics, interventions, and outcomes of lung transplant candidates referred for co-management by palliative care, to determine whether they safely received opioids and went on to transplantation.

DESIGN AND PARTICIPANTS

Retrospective review of lung transplant candidates referred to our palliative care consultation service between January 2010 and May 2012.

RESULTS

Of 308 lung transplant candidates, 64 (20.7%) were referred to palliative care. Most had interstitial lung disease and were referred for dyspnea and a rapidly deteriorating course. A total of 59 (92%) were prescribed opioids for dyspnea, 55/59 used the opioids more than once, and 38/59 were maintained on standing opioids. There were no episodes of clinically important opioid toxicity or respiratory depression, and there was a trend toward increased exertion during exercise sessions post-opioid versus pre-opioid (19.3 vs 17.0 kcal, respectively, p = 0.06). At last follow-up, 30 (47%) had been transplanted, 23 (36%) had died while on the wait-list, 9 (14%) had died after delisting, and 2 (3%) were still awaiting transplantation. Of the 30 patients who underwent lung transplantation, only 7 (23%) still required an opioid prescription 1 month post-discharge.

CONCLUSION

In lung transplant candidates, palliative care and opioids in particular can be safely provided without compromising eligibility for transplantation. Palliative care should not be delayed until a patient is deemed ineligible for transplant.

Predictors of post-traumatic psychological growth in the late years after lung transplantation

BACKGROUND

Although lung transplantation improves quality of life, most psychosocial research focuses on adverse psychological and social functioning outcomes. Positive effects, particularly in the late-term years as physical morbidities increase, have received little attention. We provide the first data on a psychological benefit - post-traumatic growth (PTG) - and we focused on long-term (>5 yr) survivors.

METHODS

Among 178 patients from a prospective study of mental health during the first two yr post-transplant, we recontacted survivors 6-11 yr post-transplant. We assessed PTG (i.e., positive psychological change resulting from the transplant) and examined its relationship to other patient characteristics with multivariable regression analyses.

RESULTS

Sixty-four patients (86% of survivors) were assessed (M = 8.1 yr post-transplant, SD = 1.2). Mean PTG exceeded the scale's midpoint (M = 38.6, SD = 10.0; scale midpoint = 25). Recipients experiencing greater PTG were female (p = 0.022), less educated (p = 0.014), and had a history of post-transplant panic disorder (p = 0.005), greater friend support (p = 0.048), and better perceived health (p = 0.032). Neither other pre- or post-transplant mood and anxiety disorders nor transplant-related morbidities (acute rejection, bronchiolitis obliterans syndrome) predicted PTG.

CONCLUSIONS

PTG exceeded levels observed in other chronic disease populations, suggesting that lung transplantation may uniquely foster positive psychological change in long-term survivors. PTG occurs despite physical and psychiatric morbidities. Whether PTG promotes other positive post-transplant psychosocial outcomes deserves attention.

Nature and correlates of post-traumatic stress symptomatology in lung transplant recipients

BACKGROUND

The burden of post-traumatic stress disorder (PTSD) symptoms may be associated with worse outcomes after transplantation. Little is known about the prevalence and correlates of PTSD symptoms in lung transplant recipients.

METHODS

We conducted a cross-sectional study of lung transplant recipients between April 2008 and February 2010 at a single center. The PTSD Checklist was used to determine the burden of PTSD symptomatology (total score) and percent of subjects with a provisional PTSD diagnosis (validated algorithms). We assessed the relationship between PTSD symptom burden and patient characteristics with multivariable logistic modeling.

RESULTS

We enrolled 210 subjects (response rate 91%). Most patients were female (50%), and Caucasian (89%). The median age was 59 (interquartile range [IQR] 48 to 63) years and the median time between transplant and follow-up was 2.4 (IQR 0.7 to 5.3) years. Clinically significant PTSD symptomatology was observed in 12.6% (8.4% to 17.9%) of subjects. Subjects were more likely to endorse symptoms of re-experiencing (29.5%) and arousal (33.8%) than avoidant symptoms (18.4%). Multivariable linear regression showed higher PTSD symptom scores among recipients who were: younger (p < 0.001); without private insurance (p = 0.001); exposed to trauma (p < 0.001); or diagnosed with bronchiolitis obliterans syndrome (p = 0.005).

CONCLUSIONS

Overall prevalence of PTSD (12.6%) in our study was two times higher than the general population. Patient characteristics found to be associated with an increased burden of PTSD symptoms may be useful to consider in future interventions designed to reduce this comorbidity.

Onset and risk factors for anxiety and depression during the first 2 years after lung transplantation

OBJECTIVE

Anxiety disorders are prominent in chronic lung disease; lung transplant recipients may therefore also be at high risk for these disorders. We sought to provide the first prospective data on rates and risk factors for anxiety disorders as well as depressive disorders during the first 2 years after transplantation.

METHOD

A total of 178 lung recipients and a comparison group (126 heart recipients) received psychosocial and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition assessments at 2, 7, 12, 18 and 24 months posttransplant. Survival analysis determined onset rates and risk factors.

RESULTS

The panic disorder rate was higher (P<.05) in lung than heart recipients (18% vs. 8%). Lung and heart recipients did not differ on rates of transplant-related posttraumatic stress disorder (15% vs. 14%), generalized anxiety disorder (4% vs. 3%) or major depression (30% vs. 26%). Risk factors for disorders included pretransplant psychiatric history, female gender, longer wait for transplant, and early posttransplant health problems and psychosocial characteristics (e.g., poorer caregiver support and use of avoidant coping).

CONCLUSIONS

Heightened vigilance for panic disorder in lung recipients and major depression in all cardiothoracic recipients is warranted. Strategies to prevent psychiatric disorder should target recipients based not only on pretransplant characteristics but on early posttransplant characteristics as well.