Psychological adjustment after cardiac transplantation

Personality changes following heart transplantation: The role of cellular memory

Personality changes following heart transplantation, which have been reported for decades, include accounts of recipients acquiring the personality characteristics of their donor. Four categories of personality changes are discussed in this article: (1) changes in preferences, (2) alterations in emotions/temperament, (3) modifications of identity, and (4) memories from the donor's life. The acquisition of donor personality characteristics by recipients following heart transplantation is hypothesized to occur via the transfer of cellular memory, and four types of cellular memory are presented: (1) epigenetic memory, (2) DNA memory, (3) RNA memory, and (4) protein memory. Other possibilities, such as the transfer of memory via intracardiac neurological memory and energetic memory, are discussed as well. Implications for the future of heart transplantation are explored including the importance of reexamining our current definition of death, studying how the transfer of memories might affect the integration of a donated heart, determining whether memories can be transferred via the transplantation of other organs, and investigating which types of information can be transferred via heart transplantation. Further research is recommended.

Body Image in Liver Transplantation Recipients

Body image (BI) concerns have been reported to play a significant role in the psychological adaptation after organ transplantation. There is a paucity of data about BI beliefs in liver transplant recipients. We report the results of a cross-sectional study of 177 liver transplant recipients for whom we assessed BI, anxiety, depression, and quality of life (QOL) using validated instruments. Our results indicate that higher BI concerns correlated with higher levels of anxiety and depression. BI concerns were more elevated in females, younger patients, and patients with a lower income. Patients with chronic liver disease had more BI concerns than patients who received liver transplantation for acute liver failure. Specific BI concerns also correlated independently with QOL scores. We conclude that BI concerns are significant in liver transplant recipients and should be evaluated by clinicians involved in the mental health care of this population.

Attitudes of Potential Candidates for Heart and Heart-Lung Transplantation to Xenotransplantation

Context and Objectives

Whether the fact that a transplanted organ is non-human would affect acceptance levels among potential recipients of heart and heart-lung xenografts has not been determined. Studies in renal patients have produced contradictory results. Furthermore, no previous studies have examined the attitudes toward xenotransplantation among the chief caregivers of potential transplant recipients.

Participants and Measures

Fifty-nine patients and 54 caregivers responded to a questionnaire that requested their views on xenotransplantation, the source and level of their knowledge about xenotransplantation, and the perceived costs and benefits of this intervention. Patients' and caregivers' attitudes to animal experimentation and killing animals for human benefit were also assessed by using a specifically designed attitude questionnaire.

Results

Fifty-six percent of patients and 48% of caregivers were unsure about xenotransplantation. Seventy-nine percent of patients and 85% of caregivers indicated that they had received little or no information about xenotransplantation, and what information they had received was from nonmedical sources. Availability of organs was the main perceived benefit (36% of patients and 40% of caregivers) and ethical and moral issues were the main perceived cost (20% of patients and 25% of caregivers). Overall patients and caregivers were in agreement with animal experimentation and killing animals for human benefit.

Conclusions

Potential heart and heart-lung recipients and their caregivers have limited information about xenotransplantation and are currently unsure about the acceptability of this procedure. Although this uncertainty may be due to their lack of information about this intervention, it may also reflect concerns about the morality of breeding animals solely to provide organs for transplantation.

Body image in transplant recipients and living organ donors

PURPOSE OF REVIEW

The purpose of this article is to describe the current evidence regarding the prevalence and significance of concerns about body image in transplant recipients and organ donors.

RECENT FINDINGS

Body image and organ integration concerns have been reported as main themes in the psychological adaptation to transplantation. Their prevalence, severity, description and impact vary wildly. There is a lack of validated instruments to measure body image or organ integration in transplant patients. For organ recipients, satisfaction with body image depends on the organ, genre, pretransplant medical illness, time since transplantation and post-transplant medication regimen. Complete or partial denial of the graft is frequently reported. For organ donors, body image is influenced by the type of surgical incision. There is little evidence that body image or organ integration impact medical or psychological outcomes after transplantation or organ donation.

SUMMARY

Body image is becoming a significant component of measuring the quality of life in transplant patients. Body image may become a factor in decisions about if and when to pursue transplant for nonlife-threatening conditions (e.g. face transplantation), about the type of incision or about the immunosuppressant regimen. For mental health professionals, understanding the complexities of body image and organ integration will help enhance the assistance provided before and after transplant or donation.

Living with a heart transplant: a phenomenological study

BACKGROUND

Heart transplantation is a relatively new medical treatment for end-stage heart failure. Many studies have addressed the outcomes and the complications and technical problems associated with heart transplants, but few have explored the whole clinical experience of being a heart transplant recipient.

PURPOSE

To understand and gain deeper insight into the lived experience of Iranian heart transplant recipients.

METHODS

Interviews of 11 heart transplant recipients were analyzed according to phenomenological guidelines set forth by Diekelmann.

RESULTS

Six major themes emerged from 29 subthemes, depicting the meaning of living with a transplanted heart. These themes include having a new life, living with new concerns, living with vigilance, paradoxical emotions, bearing others' behaviors, and the prominent role of God in life.

CONCLUSION

Heart transplant recipients in Iran experience a new life in which their faith in God helps them go through hardships and difficulties.

Predicting quality of life with a pretransplantation assessment battery: A prospective study of cardiac recipients

This study provides descriptive data on the prevalence of symptoms and quality of life of cardiac transplantation recipients and tests the predictive validity of a pre-cardiac transplantation psychological assessment battery on posttransplantation quality of life. Following the formation of four cluster groups of pretransplantation MMPI profiles based on previous research, frequency analysis found that the cluster groups were not equally represented among cardiac recipients, such that the "Distressed/Confused" cluster had only one recipient member. Tests of significance among the three remaining cluster groups on the posttransplantation quality of life variables found no significant differences. Regression analyses to test the predictive validity of other pretransplantation medical and psychological variables indicated that trait anxiety was a significant predictor of increased symptom frequency and symptom problems and decreased mental health among recipients. Collectively, modest support was found for the use of pretransplantation psychological variables as predictors of posttransplantation quality of life. Interpretation of psychological test data in the context of other psychosocial variables is discussed.

Psychological adaptation and quality of life of adult intestinal transplant recipients: University of Bologna experience

INTRODUCTION

Intestinal transplantation has become an accepted therapy for individuals permanently dependent on total parenteral nutrition (TPN) with life-threatening complications. Quality of life and psychological well-being can be seen as important outcome measures of transplantation surgery.

METHODS

We evaluated 24 adult intestinal transplant recipients and 24 healthy subjects (a control group). All subjects were administered the Italian Version of the Psychological Well-Being Scales (PWB) by C. Ryff, the World Health Organization Quality of Life-Brief (WHOQOL), and the Symptom Questionnaire (SQ) by R. Kellner and G.A. Fava, a symptomatology scale. Quality of life and psychological well-being were assessed in transplant recipients in relationship to the number of rejections, the number of admissions, and the immunosuppressive protocol.

RESULTS

Intestinal transplant recipients reported significantly higher scores in the "personal growth" category (P = .036) and lower scores in the "positive relation with others" (P = .013) and "autonomy" (P = .007) dimensions of PWB, compared with the controls. In the WHOQOL, the scores of transplant recipients were lower only in the psychological domain (P = .011). Transplant recipients reported significantly higher scores in the "somatic symptom" (P = .027) and "hostility" (P = .018) dimensions of the SQ, compared with the controls. Transplant recipients with number of admissions >8 reported higher scores in "anxiety" (P = .019) and "depression" (P = .021) scales of the SQ, and the patients with a Daclizumab protocol reported higher scores in "depression" (P = .000) and "somatic symptom" (P = .008) of the SQ. There were no significant differences regarding number of rejections and socio-demographic variables.

CONCLUSION

Improvement of psychological well-being in the transplant population may be related to the achievement of the goal of transplantation: recovery of bowel function. But the data confirmed that the transplant experience required a long and difficult adaptation trial to the new condition of "transplant recipient."

Chronic ischemia and neurocognition

Cognitive impairment from a major stroke as a consequence of carotid disease is an acknowledged clinical outcome; however, cognitive impairment without major stroke is open to discussion. The three recognized mechanisms for cognitive dysfunction from internal carotid artery are microembolization, white-matter disease, and hypoperfusion. The last has been most difficult to characterize physiologically. In this article, the authors review evidence supporting the existence of chronic ischemia in the brain and its direct impact on cognitive functions. By incorporating the pathophysiology of chronic ischemia into the algorithm of the management of carotid artery disease, we may be able to extend the goals of carotid artery revascularization beyond merely preventing stroke to include preventing or reversing cognitive decline.

Assessing exercise performance after heart transplantation

OBJECTIVE

Heart transplantation improves the survival rate and quality of life in patients with severe symptoms of congestive heart failure and an ejection fraction of 20% or less. Despite marked symptomatic and clinical improvement in those who undergo heart transplantation, exercise capacity often remains reduced, and the factors limiting exercise performance during the post-transplantation period remain unclear. This study was performed to investigate the factors affecting exercise capacity in heart transplantation recipients.

PATIENTS AND METHODS

Fourteen patients with cardiomyopathy were enrolled in this study. We measured peak exercise oxygen uptake (peak VO(2)) in seven patients (age range: 42 +/- 14 yr) 10-28 months after transplantation, in seven patients (age range: 33 +/- 18 yr) with dilated cardiomyopathy before heart transplantation, and in 14 healthy control subjects (age range: 44 +/- 12 yr). The left ventricular ejection fraction, Beck Depression Inventory score, Medical Outcome Health Survey Short Form-36 Questionnaire (SF-36) results, and immunosuppressive therapy administered were recorded in all patient groups.

RESULTS

All patients in the post-transplantation group terminated exercise testing before the anaerobic threshold because of general fatigue. All heart transplantation recipients exhibited a left ventricular ejection fraction within the normal range (mean +/- SD = 57% +/- 2%). The peak VO(2) mean values were significantly different among the three groups (p = 0.001). There were statistically significant correlations between the peak VO(2) values and the Beck Depression Inventory scores (r = -0.637, p = 0.01), between the peak VO(2) values and bodily pain (r = 0.717, p = 0.006), between the peak VO(2) values and general health perceptions (r = 0.706, p = 0.007), and between peak VO(2) values and postoperative duration (r = 0.843, p = 0.03) in all patient groups.

CONCLUSION

In the long-term treatment of heart transplant recipients, exercise training should be considered an important therapeutic tool that enables patients to achieve a good quality of life.

Patterns and predictors of quality of life at 5 to 10 years after heart transplantation

BACKGROUND

Although studies have provided us with a cross-sectional analysis of long-term quality of life (QOL) after transplantation, relatively few longitudinal studies have been done that allow us to understand changes in QOL over time. The purposes of our study were to describe QOL over time and identify predictors of QOL longitudinally from 5 to 10 years after heart transplantation.

METHODS

All 555 subjects enrolled in this study completed booklets of questionnaires. These patients had a mean age of approximately 54 years (range 21 to 75 years) at time of transplant. Seventy-eight percent were men and 88% were white. Participants completed nine self-report QOL instruments for this study. Statistical analyses included frequencies, means +/- standard deviations (plotted over time), Pearson correlation coefficients and multiple regression coupled with repeated measures.

RESULTS

At 5 to 10 years after heart transplantation, recipients reported high levels of satisfaction with overall QOL and with health-related QOL, which was stable over the 5-year period. Predictors of satisfaction with overall QOL (that individually accounted for 1% variance or more) were primarily psychosocial variables (overall model explaining 71% of variance), whereas predictors of satisfaction with QOL related to health and functioning (that also explained > or =1% variance) included symptom distress and physical function, as well as psychosocial variables (overall model explaining 72% of variance).

CONCLUSIONS

At 5 to 10 years after heart transplantation, QOL remained positive and stable. Bio-psychosocial variables predicted satisfaction with overall QOL and health-related QOL. Understanding of these bio-psychosocial variables provides direction for the development of long-term therapeutic strategies after heart transplantation so that patients can have good post-transplant outcomes.

Predictors of quality of life at 5 to 6 years after heart transplantation

BACKGROUND

Only a few researchers have examined quality of life (QOL) outcomes more than 5 years after heart transplantation. Therefore, the purpose of this study was to describe QOL (overall, satisfaction with, and perceived importance); identify differences in QOL by age, sex, and race; and identify predictors of QOL at 5 to 6 years after heart transplantation.

METHODS

A nonrandom sample of 231 patients (60 years of age, 76% men, 90% white, 79% married, and fairly well educated) who were 5 to 6 years after heart transplantation were investigated. Patients completed 12 QOL instruments via self-report. Data analyses included descriptive statistics, chi2, independent t-tests, correlations, and stepwise multiple regression. Level of significance was set at 0.05.

RESULTS

Patient satisfaction with all areas of life was high at 5 to 6 years after heart transplantation. Similarly, patients believed that these same areas of life were very important. Yet areas of QOL with lower levels of satisfaction were identified. Patients who were > or =60 years were more satisfied with their QOL than patients <60 years. At 5 to 6 years after heart transplantation, almost 80% of variance in QOL was explained by psychological, physical, social, clinical, and demographic variables.

CONCLUSIONS

At 5 to 6 years after heart transplantation, patients were very satisfied with their QOL, although differences in level of satisfaction were identified by demographic variables, and areas of QOL with lower levels of satisfaction were identified. Understanding those variables that contribute to QOL in the long term after heart transplantation provides direction for assisting patients to improve their QOL.

Social adaptation after cardiothoracic transplantation: a review of the literature

From the earliest days of transplantation, research has contributed to our knowledge of the psychosocial sequelae associated with the outcomes of the procedure. The purpose of this review is to describe the social adaptation literature for heart, lung, and heart-lung recipients. Social adaptation refers to employment and performance of social roles and responsibilities. Employment research focused on vocational rehabilitation, physical health restoration, and return to work. Social roles and responsibilities research focused on social roles, family relationships, social support, and psychosocial adjustment. Predictors, interventions, and their associations with outcomes are discussed.

Psychologic Stages in Renal Transplant

Health workers must be aware of the psychologic stages experienced by their patients. We analyzed the influence of the posttransplant time on thoughts (depressive and anxious) and body image perception in renal transplant recipients. The sample consisted of 59 adult patients (mean age +/- SD: 45.76 +/- 11.44), divided into three groups according to the posttransplant time (1 year, 1 to 2 years, >2 years). Subjects completed a psychosocial interview (sociodemographic and clinical data), the Beck's Cognitions Checklist, and the Garanto Self-concept Scale. Negative thoughts and body image alterations were increased during the first year and from the third year on, with no statistically significant differences between these two periods, but they were appreciable when these periods were compared with the 13- to 24-month interval. Renal transplant recipients may go through three psychologic stages after transplant: alert; coping; and exhaustion.

Depression and Anxiety in the Heart Transplant Patient

Depression and anxiety are potential psychological problems that a heart transplant patient may face both before and after transplant. In addition, there is the potential for difficulty in adjusting to life after transplantation. Anxiety and depression and their effects, both pretransplant and posttransplant, are explored. A case study is used to illustrate the psychological effects of trans plantation.

Change in quality of life from after left ventricular assist device implantation to after heart transplantation

BACKGROUND

No studies have analyzed quality of life (QOL) from before to after heart transplantation in patients with a left ventricular assist device (LVAD). Therefore, the purpose of this longitudinal, multi-site study was to compare QOL outcomes of patients listed for heart transplantation who required a left ventricular assist device (LVAD) at 3 months after implantation of an LVAD vs 3 months after heart transplantation.

METHODS

A non-random sample of 40 patients (predominantly middle-aged, married, white men), who had paired data at both 3 months after LVAD implantation and 3 months after heart transplantation, were investigated. Patients completed self-report questionnaires (with acceptable reliability and validity) at both time periods, including the Quality of Life Index, Rating Question Form, Heart Failure Symptom Checklist, Sickness Impact Profile, LVAD Stressor Scale (completed only after LVAD implant), Heart Transplant Stressor Scale (completed only after heart transplant) and Jalowiec Coping Scale. Descriptive analyses and comparative analyses using paired t-tests were performed with statistical significance set at 0.01.

RESULTS

Patients were significantly more satisfied with their lives overall and with their health and functioning at 3 months after heart transplantation as compared with 3 months after LVAD implantation. Mobility, self-care ability, physical ability and overall functional ability improved from 3 months after LVAD implant to 3 months after heart transplant. There was significantly less symptom distress after LVAD implant as compared with after heart transplant for the neurologic, dermatologic and physical sub-scales. Work/school/financial stress was significantly lower after heart transplant vs after LVAD implant. In contrast, 2 other areas of stress were significantly lower after LVAD implant vs after heart transplant: self-care stress and hospital/clinic-related stress.

CONCLUSIONS

Differences were found in QOL outcomes at 3 months after LVAD implant as compared with 3 months after heart transplant. Our findings point out specific areas of concern with respect to QOL after LVAD implant and post-transplant, some of which are amenable to health-care provider interventions.

Quality of life after heart transplantation: are things really better?

Studies of quality of life (QOL) in heart transplant recipients have been published during the last 2 decades. More recent studies of QOL outcomes have built on previous research. Relationships between posttransplant complications and QOL, longitudinal studies of intermediate and long-term QOL, QOL in patients awaiting transplant (bridged to transplant with a left ventricular assist device), and intervention studies to improve QOL have been published recently. Is QOL better from before to after heart transplantation? The current body of literature suggests that QOL is better overall. However, change in QOL (both positive and negative) is variable based on demographic characteristics, clinical problems, QOL domain, time posttransplant, and other life events. Moreover, although more recent reports have begun to examine unanswered questions, much work remains to be done. Future studies need to be scientifically rigorous, using definitions of QOL with identification of domains to be studied; prospective, multisite, longitudinal study designs; large sample sizes; reliable and valid instruments; and appropriate statistical techniques. As changes in QOL outcomes and risks for poor QOL outcomes are identified, more intervention studies need to be developed to assist patients toward better QOL.

Attitudes of potential candidates for heart and heart-lung transplantation to xenotransplantation

CONTEXT AND OBJECTIVES

Whether the fact that a transplanted organ is non-human would affect acceptance levels among potential recipients of heart and heart-lung xenografts has not been determined. Studies in renal patients have produced contradictory results. Furthermore, no previous studies have examined the attitudes toward xenotransplantation among the chief caregivers of potential transplant recipients.

PARTICIPANTS AND MEASURES

Fifty-nine patients and 54 caregivers responded to a questionnaire that requested their views on xenotransplantation, the source and level of their knowledge about xenotransplantation, and the perceived costs and benefits of this intervention. Patients' and caregivers' attitudes to animal experimentation and killing animals for human benefit were also assessed by using a specifically designed attitude questionnaire.

RESULTS

Fifty-six percent of patients and 48% of caregivers were unsure about xenotransplantation. Seventy-nine percent of patients and 85% of caregivers indicated that they had received little or no information about xenotransplantation, and what information they had received was from nonmedical sources. Availability of organs was the main perceived benefit (36% of patients and 40% of caregivers) and ethical and moral issues were the main perceived cost (20% of patients and 25% of caregivers). Overall patients and caregivers were in agreement with animal experimentation and killing animals for human benefit.

CONCLUSIONS

Potential heart and heart-lung recipients and their caregivers have limited information about xenotransplantation and are currently unsure about the acceptability of this procedure. Although this uncertainty may be due to their lack of information about this intervention, it may also reflect concerns about the morality of breeding animals solely to provide organs for transplantation.

Psychosocial and behavioral selection criteria for solid organ transplantation

An evidence-based selection process for organ transplantation may be a valuable approach to improve posttransplant outcomes. This paper reviews state-of-the-art psychosocial and behavioral selection criteria and assesses their validity in view of predicting outcomes after transplantation. Psychosocial factors addressed are psychiatric disorders, mental retardation, irreversible cognitive dysfunction, and lack of social support. Behavioral selection criteria discussed are alcoholism, smoking, drug abuse, and obesity. This review reveals that the evidence concerning these selection criteria in scarce. There is a definite need for more longitudinal research to strengthen the scientific basis of the psychosocial and behavioral dimension of transplantation.

Psychiatric morbidity in patients undergoing heart, heart and lung, or lung transplantation

OBJECTIVES

To determine the rate of psychiatric disorder in people undergoing heart and/or lung transplantation; to identify the associations of psychiatric disorder in this group.

METHOD

Preoperative assessments were carried out on an 18-month sample of consecutive admissions to a regional unit for heart and lung transplantation in the UK. Assessment included psychiatric morbidity, sexual dysfunction, quality of life, and demographic and clinical characteristics.

RESULTS

Seventy-six of 79 eligible subjects took part in the assessment. Thirty (39%) were suffering from a psychiatric disorder, the most common being major depressive disorder. Forty-four (58%) reported sexual dysfunction. Clinically significant psychiatric morbidity was associated with a history of treatment for mental disorder, unemployment, and length of physical illness. Patients with psychiatric disorder reported poorer quality of life on the SF-36, with lower scores on subscales for general health perception, social functioning, and energy/vitality.

CONCLUSION

There is a substantial rate of psychiatric disorder in people undergoing heart and/or lung transplantation. Risk is higher in people with a history of psychiatric vulnerability and current illness-related factors. Preoperative psychiatric assessment and intervention in some patients may be a valuable part of their clinical care.

Sexuality of patients with advanced heart failure and their spouses or partners

BACKGROUND

Sexuality is an important aspect of quality of life for patients with advanced heart failure and their spouses or partners. Therefore, we conducted a study to determine the types of sexual problems and concerns of patients and their spouses/partners, their level of interest in receiving information on this topic, and the relationship between their need for information and the degree of sexual problems.

METHODS

Sixty-three couples were recruited from a university-affiliated, outpatient, heart failure program during their initial visit.

RESULTS

The most important sexual relationship issue of both patients and spouses/partners was related to decreased frequency in sexual relations. They reported the need to receive specific information about sexual activity as moderate to very high, but it was unrelated to the level of need for education and counseling.

CONCLUSIONS

Nurses and physicians need to assume interest and provide instruction related to the sexual activity needs of patients and their spouses/partners.

Preoperative psychosocial predictors of hospital length of stay after heart transplantation

The effect of psychosocial factors on hospital length of stay (LOS) after heart transplantation has not been reported. This study examines relationships between preoperative psychosocial variables and LOS and identifies preoperative psychosocial predictors of LOS after transplant. A nonrandom sample of 307 patients at two medical centers completed a self-administered booklet of psychosocial measures. A chart review was also conducted. Psychosocial problems included anxiety, stress, and inadequate coping; questionable understanding of heart failure and treatment; substance abuse; and noncompliance. Self-care disability, a history of noncompliance, and more emotional disability predicted 8% of LOS. This supports the inclusion of psychosocial issues and functional disability in post-heart transplant clinical pathways.

Psychological and cognitive status before and after heart transplantation

Advances in the technical aspects of heart transplantation and the medical management of rejection have allowed a shift toward research evaluating psychological factors affecting heart transplant candidates and psychosocial sequelae following transplantation. This study examined the psychological and cognitive status of patients presenting for heart transplant evaluation. The findings indicated that this patient group was characterized by impaired verbal memory and a tendency toward depression and anxiety. The second part of the study examined changes in psychological and cognitive status from the initial evaluation to a follow-up assessment 1 year after transplantation. The results indicated that psychological distress (depression, anxiety) and several indices of cognitive function improved after transplantation. Finally, correlations were determined to evaluate the association between the psychological and cognitive measures and episodes of rejection in the first 6 months after transplantation. Anxiety, depression, and a nonverbal measure of intelligence were found to be associated with the number of episodes of rejection. The implications of these findings are discussed.

Predicting completeness of symptom relief after major heart surgery

The authors hypothesized that the same biopsychosocial factors that raise the risk of illness incidence would influence the speed and completeness of relief from physical symptoms during recovery following cardiac surgery. This multicenter prospective study involved 463 patients aged 35 to 69 years who underwent coronary artery bypass graft or cardiac valve surgery. Predictor data were gathered 1 to 3 days before surgery, and outcome measures were collected 6 months postoperatively. The following predictors were associated with postoperative freedom from cardiac symptoms: fewer preoperative cardiac hospitalizations; low levels of angina, dyspnea, fatigue, and sleep problems; low levels of anxiety, depression, hostility, and life-change events; and high levels of psychosocial well-being, hopefulness, overall satisfaction, and social support. The predictors of not requiring daytime bed rest because of cardiac symptoms during the 6th postoperative month were male gender, higher education, less cardiac disability preoperatively, low levels of angina, dyspnea, sleep problems, depression and fatigue, and absence of Type A behavior and of intraoperative hypotension. By using separate multiple logistic regression equations, the authors identified the variables printed in bold face as independent significant contributors to prediction. Many of the predictors are strong enough and simple enough to be used in clinical practice. Many of them may also predict recovery after acute illnesses and injuries involving other organ systems.

The future of organ transplant psychiatry

The future of organ transplant psychiatry depends less on immunologic and surgical advances than on 1) an increased supply of donor organs, 2) more sophisticated multicenter outcome studies, and 3) understanding of the subjective as well as objective aspects of compliance and quality of life for transplant recipients. From future studies, we may improve the selection process for candidates and discover which approaches are optimal for anxiety, depressive, organic mental, and personality disorders. Absolute contraindications to transplantation may become relative. Integration of ethical concerns with biomedical and psychosocial criteria for selection will challenge future investigators given the inadequate supply of donor organs.

Psychiatric aspects of heart transplantation

There are many practical psychiatric, social, and ethical problems which accompany heart transplantation. These include pre- and postoperative anxiety and depressive conditions, post-operative delirium, and social and family dysfunctional syndromes. This paper reviews the literature critically in the following five areas: pre-transplant evaluation, coping with surgery, postoperative sequelae, rehabilitation, and management. Although most recipients have a good outcome from the physical and psychiatric points of view, a substantial minority experience family conflicts and sexual dysfunction after surgery. An average of 45% of patients from all studies returned to full-time employment. The distinctive role and contribution of the psychiatrist on the transplant team is discussed and important areas for future research are outlined.

Compliance with the medical regimen and partner's quality of life after heart transplantation

The authors investigated 40 heart transplant recipients and their partners to determine both the partner's quality of life upon transplantation and the experiences of both patient and partner with compliance with the medical regimen. Data on sleep disturbances, social isolation, emotional reactions, depression, anxiety, partner's apprehension, social support and compliance (regarding behaviour and emotional experience) were obtained approximately 21 months after transplantation. Compared to related study groups, partners did not experience more problems in sleep, social isolation, emotional reactions, depression and anxiety. Patients overestimated the apprehension of their partners significantly (p < 0.0001). Generally speaking, with the exception of three items relating to eating fish, canned food and forgetfulness in medicine intake, patients and partners agreed with respect to actual compliance behaviour. Lowest compliance concerned regular physical exercise: 28%. Both patient and partner insisted that they had scarcely any emotional problem with the regimen. Further systematic research is needed to bring to light factors that affect compliance as well as adequate methods to bring about an improvement therein.

Living with a disability: a synthesis and critique of the literature on quality of life, 1985-1989

The current study describes articles cross-indexed under the keywords "quality of life" and "disability" in Index Medicus for the years 1985 through 1989 to compare their relative merits in terms of research design, sampling details, and the type of quality of life criteria included. Of 833 articles indexed under "quality of life," 52 (16%) included data about a disabling condition requiring rehabilitation. Of those 52, only seven (13%) were randomized clinical trials. The modal design was a descriptive survey or case study (N = 22 or 42%). Given the limited rigor in research design and invalid measurements, conclusions about improvement in the quality of life for disabled individuals after rehabilitative care could not be drawn from the studies reviewed. It may be concluded that research on quality of life needs to be better designed and should include more uniform and valid criteria.

Psychiatric aspects of heart transplantation

This article, part of a series on organ transplantation, will review psychiatric aspects of heart transplantation, starting with a brief summary of medical aspects. The authors then review psychiatric symptoms and syndromes frequently encountered pre-, peri-, and posttransplantation; the selection of candidates; and treatment of psychopathology.

Cognitive development and learning in the pediatric organ transplant recipient

Although organ transplantation is considered a viable treatment approach for end-stage organ disease, few empirical investigations have assessed the effects of transplantation on the cognitive development and learning of pediatric organ transplant recipients. This article reviews studies evaluating neurocognitive changes following organ transplantation in pediatric end-stage renal and liver disease. Despite numerous methodological problems inherent in the investigations examined, the findings of some studies are suggestive of potential neurocognitive benefits associated with organ transplantation. Recommendations are made regarding methodological improvements for future investigations assessing neurocognitive outcomes of organ transplantation.

Psychosocial problems of donor heart recipients adversely affecting quality of life

Heart transplantation has become an accepted therapy for patients suffering from terminal heart disease for whom neither standard forms of medication nor the usual surgery are of any benefit. Although results regarding postoperative quantity and quality of life are encouraging, it must not be overlooked that the patient and his family face, and have to overcome, profound psychosocial problems. The main stressors were identified in interviews with 47 heart transplant patients. The main preoperative problems were: the way of being informed about the diagnosis, the waiting period for transplantation, anguishing doubts about the decision to have a transplant, being a body without heart ('zombie'), guilt and shame regarding the donor, the reactions of others. Postoperatively the patients have to cope with: re-entering social systems, reactions of friends, neighbours and colleagues, rejection episodes, death of a fellow patient, the need to redesign family life. All the problems reported by the patients interviewed are discussed regarding their psychosocial implications, and hints are given on how to minimize them.

Transplantation in Australia--50 years of progress

OBJECTIVE

To review the history of clinical transplantation practice in Australia.

DATA SOURCES AND STUDY SELECTION

The first major source was published reports, chiefly in The Medical Journal of Australia (129 articles). The second source was personal communication with those involved in early and current transplantation programs.

DATA EXTRACTION AND SYNTHESIS

The first known transplant of each organ in Australia and the results of current programs have been documented.

CONCLUSIONS

Transplantation of the kidney, liver, heart, lung, pancreas, cornea, or bone marrow are available and accepted therapies for an increasing number of suitable patients, limited mainly by the number of donors.

Longitudinal study of quality of life and psychological adjustment after cardiac transplantation

OBJECTIVE

To assess the psychological adjustment and quality of life of a sample of cardiac transplant recipients over time.

DESIGN

The patients were consecutive recipients of new hearts which were transplanted between November 1984 and December 1986. Thirty-eight patients were entered into the study, but at final follow-up only 27 were assessed; six patients had died and five could not be contacted. Patients were seen before transplantation, at discharge, then at 4, 8 and 12 months after transplantation and finally at a mean of 4.2 years after transplantation. They were assessed by means of standardised questionnaires. The results were compared across time and correlated with demographic data and medical data collected at the initial assessment. Only patients who were alive and responded at each point of follow-up were included in the study.

SETTING

All patients were seen at St Vincent's Public Hospital and were tertiary care patients.

MAIN OUTCOME MEASURES

The main outcome measures were anxiety, depression and well-being. These measures were assessed by means of the Spielberger State Trait Anxiety Scale, the Beck Depression Inventory and the Campbell Well-Being Scale. At the four year follow-up the Nottingham Health Profile was also used.

RESULTS

Scores for anxiety, depression and well-being improved significantly after transplantation and did not deteriorate over time. No significant correlations were found between psychological measures and medical or demographic data.

CONCLUSIONS

The results showed no evidence of mood disorder and a high level of well-being in this sample of cardiac transplant recipients up to four years after transplantation.

Psychosocial outcome six months after heart transplant surgery: a preliminary report

With improvement in survival of patients treated with heart transplant, evaluation of recovery with respect to psychosocial function has become an important issue. In this study, psychosocial functioning of 44 heart transplant recipients pretransplant was compared to their functioning 6 months posttransplant. Before transplantation, patients experienced considerable psychosocial distress attributable to illness. At 6 months after transplantation, the majority of patients showed significant improvement in emotional, domestic, sexual, social, and vocational functioning. However, 25% of patients showed deterioration in psychosocial adjustment and 11% showed an increase in mood disturbance. Further effort is indicated to improve psychosocial outcome of heart transplantation.

Psychosocial, neuropsychological and neurological status in a sample of heart transplant recipients

The sample for this psychosocial follow-up study was formed using the 71 surviving patients from a total of 100 who underwent heart transplantation up until March 1990 at Kiel University Hospital. Forty of these could be investigated comprehensively. The neurological investigation comprised EEG and auditory and visually evoked potentials. The psychological investigation started with several neuropsychological tests; additionally all patients were interviewed and they completed questionnaires concerning anxiety, depression, ways of coping, personality characteristics and life satisfaction. Within the entire sample, there were few indications for specific psychological impairment. The psychosocial status of the patients was not significantly related to the time which had elapsed since they underwent transplantation. There were few associations between neuropsychological and psychosocial data, and several indicators of early postoperative complications which are described in the literature (e.g., length of stay in the intensive care unit). Clinically relevant subgroups (formed on the basis of neuropsychological test results, anxiety and depression) did not differ in terms of these indicators. Nevertheless, a considerable proportion of the patients (25%) were characterized by having a higher level of affective and neuropsychological impairment. Although based upon retrospective investigations, the results of this follow-up generally correlate with those gained from Anglo-American countries. In interpreting the results one needs to consider the possible influence of premorbid personality characteristics as well as denial which may be typical for patients undergoing heart transplantation.

Quality of life after organ transplantation

Organ transplants are being conducted with increasing frequency. It is generally known that these procedures increase length of life, but less is known about the quality of that life. In this paper, the literature pertaining to quality of life of patients with kidney, pancreas, heart, heart-lung, liver and bone marrow transplants is reviewed. On the basis of this review, it seems that quality of life after kidney and heart transplantation is very good, when compared to the pretransplant state. However, more research is required to examine quality of life of recipients of other types of transplantation. There are many issues that pertain to measurement of quality of life that remain to be addressed. These include: definitions of quality of life, dimensions of quality of life, expectations of quality of life and clinical assessment of quality of life.

Psychosocial effects of cardiac transplantation

As more cardiac transplant procedures are performed, the psychosocial implications of the procedure can be identified and investigated. The process of cardiac transplant can be viewed as a series of stages and adaptive tasks which begin with the proposal of transplant and progress to successful postoperative adaptation. The suggestion of transplant may evoke feelings of anxiety and ambivalence as patients realize that transplant may be their only option for long-term survival. The evaluation process determines the need for transplant and whether there are circumstances that might limit post-transplant survival. Psychosocial evaluation is important as survival depends in part on the recipient's ability to cope with stressors and comply with a complex medical regimen. This evaluation is not standardized, and research continues to identify reliable predictors of postoperative behavioral and psychiatric complications. The wait for a donor may be the most stressful of all stages as candidates deal with increasing symptoms, increasingly intensive medical management and the fear of a donor will not be found in time. Following successful surgery, heart recipients and their families express feelings of joy and relief. During convalescence, adjustment difficulties may arise in the form of transient depression or body image concerns. After recipients are discharged from the hospital, they must comply with intensive medical follow-up to monitor their health. They continue to be vulnerable to physical, emotional and financial problems.(ABSTRACT TRUNCATED AT 250 WORDS)