Hepatitis C is the leading reason for orthotopic liver transplant, followed by alcoholic liver diseasese (1). Transplant candidates’ medical and psychiatric histories are frequently intertwined. It is important to understand the etiology, course, and current symptoms of the patient’s liver failure. Encephalopathy, disturbed sleep-wake cycle, fatigue, weakness, and forgetfulness are common in this population.
A detailed history of the patient’s alcohol and other substance use should be elicited. For each substance, ask about the duration of use, the quantities used, the level of interference it caused with work and social function, legal problems, the duration of previous sobriety and how it was achieved, why relapses occurred, current use of the substance or current duration of sobriety, and supports for maintaining sobriety. Although patients with alcoholic liver failure generally do not believe that they are at risk of relapse (2), 30%—50% of transplant patients with alcoholic liver disease resume drinking by 5 years after transplant (3), and an estimated 10% of this group return to heavy drinking and have medical complications (4). Most transplant programs require that candidates have 6 months of sobriety. However, the literature demonstrates that prior nonalcohol substance use, a family history of alcoholism in a first-degree relative, and prior alcohol rehabilitation experience are better predictors of relapse than ability to maintain abstinence for 6 months (5).
A complete psychiatric history and review of current symptoms may uncover signs of delirium, depression, and anxiety. Trzepacz et al. found that 18.6% of liver transplant candidates had delirium (6). In a study of alcoholic transplant candidates, DiMartini et al. found lifetime prevalence rates of 36% for major depressive disorder and 12% for anxiety disorders (7). Psychiatric symptoms that may exclude a transplant candidate include active suicidal ideation, active psychosis or schizophrenia, and acute mania. If any psychiatric syndrome is identified, it should be treated appropriately and the patient reassessed when stable.