Journal Article Annotations
2023, 3rd Quarter
Annotations by Sarah R Andrews, MD, Gregory Nikogosyan, DO
October, 2023
The finding:
This best practice guidance developed by transplant psychiatrists and psychologists focus on treatment of depression in solid organ transplant recipients. The recommendations suggest that all organ transplant recipients should be screened regularly for depression. Following a positive screening, a mental health provider should be notified and/or a further clinical evaluation should be completed. If patients meet criteria for a depressive disorder, treatment should be offered, which can include psychotherapy and/or antidepressants. Treating depression post-transplant is recommended.
Strength and weaknesses:
One of the strengths of this paper is that it is the first best practice guidance on how to manage psychiatric disorders in post-transplant recipients. The recommendations are aimed to support transplant providers in better managing patients’ depression that negatively impacts the post-transplantation process if left untreated. Some limitations of this guidance are the challenge of implementing these recommendations due to need for additional resources that may not be available in all transplant centers. This guidance is also limited by the level of evidence available in this topic area.
Relevance:
This guidance is relevant to consultation-liaison psychiatrists as these recommendations can support the care of post-transplant recipients. Guidance is provided in how to appropriately screen, refer, and then treat depression in post-transplant patients.
The finding:
Heart transplant patients with severe refractory depression may benefit from electroconvulsive therapy (ECT) despite concerns for possible adverse cardiac effects. Heart transplant patients are noted to have “cardiac super sensitivity” in the context of ECT treatment effects on heart rate and blood pressure due to parasympathetic and sympathetic surges. In this review of six cases, no imminent cardiac complications occurred, and only one patient had a significant increase in blood pressure effectively managed with antihypertensives. Furthermore, psychiatric outcomes were reported in five cases, and all showed improvement in psychiatric symptoms from the initial index ECT.
Strength and weaknesses:
Given the limited research regarding ECT for heart transplant patients, only six treatment-refractory case reports were found (five with major depressive disorder and one with bipolar disorder). The authors did not exclude any article that focused on ECT and heart transplant. The strength of this article is that this is the first review to explore patient outcomes with ECT.
Relevance:
This study supports the use of ECT for the treatment of refractory heart transplant patients notwithstanding prior concerns for adverse cardiac outcomes.
The finding:
This review concludes that multimethod assessment is the recommended practice for evaluating alcohol use disorder (AUD) in transplant patients. No one tool or assessment can replace the multimethod assessment model as there are limitations to individual approaches.
Strength and weaknesses:
The strength of this review is it explores the objective assessments available for AUD assessment in liver transplant. Such assessment domains include initial clinical interviews by medical staff, transplant-specific scoring systems, self-report measures, biomedical markers, and machine-learning models. The review highlights the need for a multimethod assessment model in part due to the significant denial or concealment of alcohol use when relying on self-report alone. This led to the recommendation for biomedical marker testing, with serum phosphatidyl ethanol demonstrating strong sensitivity, specificity, and utility in transplant patients. Furthermore, there is some data in predicting relapse with the use of the Stanford Integrated Psychosocial Assessment for Transplant, given its inclusion of comorbid psychiatric disorders. Still, this transplant-specific scoring system is noted to have statistical and methodological errors. This review’s primary limitation is the absence of large statistically powered studies from which it can draw conclusions.
Relevance:
This review highlights evidence for various tools used in pre-transplant assessment of patients with AUD and supports the multimethod assessment as the strongest format to evaluate AUD, comorbid psychopathology, and liver transplant candidacy.
The finding:
The authors publish findings from cross-sectional survey of caregivers of older patients with advanced heart failure. The authors described caregivers for three patient cohorts: patients awaiting heart transplant with pretransplant mechanical circulatory support (HT MCS), patients awaiting heart transplant on medical therapy (HT non-MCS), and patients before long-term mechanical circulatory support. Caregivers for HT non-MCS candidates reported significantly less perceived time spent on tasks and less perceived difficulty of tasks than the other two groups. The study noted heightened anxiety in the HT MCS and prior long-term mechanical support groups. The study highlighted the HT non-MCS candidate group spent significantly less time on nursing and medical treatments. HT MCS candidate caregivers were typically responsible for driveline exit site dressing changes, device troubleshooting, and other care needs. Caregivers of long-term MCS candidates were spending more time on personal care and mobility-related tasks. Of note, long-term MCS candidates reflect an older patient age and worse clinical status.
Strength and weaknesses:
The study has poor generalizability to a more diverse public, as study participants were mostly white, female, and well-educated. Furthermore, given the cross-sectional nature of this study, the exploration of participant change over time or cohort effect cannot be examined.
Relevance:
Caregiver burden and associated risk factors should be considered by the treatment team. Better assessment of caregiver support enables teams to allocate resources and maximize patients’ likelihood of recovery.