Ask the Expert: Psychiatric Evaluation of Liver Transplant Candidates

I recently completed my residency and started a practice. I have been asked by a local surgeon to evaluate patients for liver transplant. What are the crucial components of such an evaluation?

Reply from Jennifer G. Gotto, M.D., Director of CL Service at Cedars Sinai, Consultation-Liaison Service, Department of Psychiatry and Mental Health, Cedars-Sinai Medical Center, Los Angeles, California:

Psychiatrists who are part of the multidisciplinary liver transplant team have a dual responsibility: to act in the best interests of the transplant candidate and to protect the graft. The psychiatric interview and report should include six items: the candidate’s strengths and weaknesses as indicated by the medical and psychiatric history and current symptoms; history of compliance; social support; coping and personality; cognitive status (Mini-Mental State Examination [MMSE]) and understanding of the transplant procedure; and expectations, commitment, and motivation. The evaluation should conclude with an assessment of the patient’s capacity for compliance and the risk of posttransplant problems.

Medical and psychiatric history and current symptoms

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.

Compliance

Assessing the patient’s coping style and personality is a part of assessing compliance. Patients with an active coping style make an effort to understand their responsibilities associated with liver transplant, such as taking medications, keeping appointments, making appropriate lifestyle changes, and following through with assigned prerequisite tasks. Patients who have encephalopathy that interferes with their executive function and memory may have trouble meeting these responsibilities. In such cases, it is necessary to interview the primary caregiver about the patient’s capacity for compliance.

A quick review of the patient’s medical records may provide a useful history of compliance. If a patient has a history of past noncompliance but has since changed, the psychiatrist should ask the patient how he or she views that change and the reasons for previous nonadherent behaviors. If the patient has insight into “bad” behavior, it may facilitate a change toward healthier behaviors.

Social support

Given the severity of illness in end-stage liver disease, patients need comprehensive social support to get them through the peritransplant period. Lack of sufficient social support is one reason a patient’s candidacy for transplant might be rejected (8). Generally a primary caregiver is identified who will, for example, drive the patient to medical appointments, help with medications, and generally supervise the patient’s welfare (9). Caregiver responsibilities should be discussed in detail with both caregiver and patient to ensure that both understand precisely what is involved. If the primary caregiver is older and has health problems, a secondary caregiver should be available and kept informed and up-to-date so that no lapses occur in the patient’s care.

Coping and personality

Inferences about the patient’s personality and coping style can be made from his or her behavior during the psychiatric evaluation, the medical records, and caregiver reports. An “active coper” is interested in and takes responsibility for expeditiously getting on the transplant list. An “avoidant coper” needs to be pushed by the transplant team or the caregiver and requires encouragement and reinforcement of boundaries. Rarely does an avoidant coper transform into an active coper. Patients with poor coping skills may need psychosocial support from the transplant team and others to complete the transplant workup. For patients whose coping skills are so poor that their ability to care for a transplant graft is in doubt, it may be appropriate to prescribe a test period during which they are expected to meet specified appointment goals to allow patient and caregiver to demonstrate compliance.

Cognitive status (MMSE) and understanding of transplant

Liver failure affects cognition, so assessing the cognitive status of the transplant candidate is important. The MMSE should be used in the assessment, but keep in mind that it may not reveal cognitive impairment in a patient with high cognitive reserve.

Patients should have knowledge about their responsibilities regarding medications, appointments, diet, abstinence and maintaining a general healthy lifestyle after the transplant procedure. They should understand that transplantation means exchanging one set of problems—liver failure—for a new set of problems, which can include neurotoxicity from immunosuppressant medication, increased risk of infections, graft rejection, and the possibility of graft failure.

Expectations, commitment, and motivation

Explore the patient’s expectations about liver transplant. Whenever possible, address imagined fears and beliefs and educate the patient about the possibilities for his or her experience.

Negative feelings about transplant are common. Powerful negative feelings that are left unexplored may promote acting out that results in the patient’s sabotaging his or her chance for a cure for liver failure. If the patient’s ambivalence about undergoing transplant is an issue, find out its cause. The ambivalent feelings have to be dealt with in order for the patient to recognize and understand the potential benefits and risks of liver transplant.

Conclusion

Most liver transplant teams are willing to work with all types of transplant candidates, and concerns identified by the psychiatric consultant usually do not result in the patient’s being rejected from the program altogether. The complete psychiatric evaluation should contain recommendations on how the candidate might overcome any psychosocial weaknesses identified. For example, a test period might be recommended during which the candidate is expected to meet 3 months’ worth of medical appointments (or AA, or psychotherapy appointments, and so on) to give the candidate an opportunity to demonstrate compliance with a health regimen. Bear in mind, however, that there are no data showing that this practice reduces noncompliant behavior after transplant.

Providing psychiatric consultation to the liver transplant team and performing psychiatric evaluations on transplant candidates can be exciting and rewarding. A complete consultation includes the six items discussed above and, when necessary, treatment recommendations.