Psychiatric Treatment in Organ Transplant Patients

Pretransplant anxiety secondary to medical condition: Mr. J described anxiety precipitated by any movements making him feel short of breath and developed worried anticipation of any future physical activity. He was assessed to be an appropriate transplant candidate from a psychiatric perspective. He was diagnosed with anxiety due to a general medical condition and was treated with a combination of mirtazapine, gabapentin, guanfacine, and supportive psychotherapy. However, his respiratory failure progressed, and he required intubation and placement on extracorporeal membrane oxygenation.

Postoperative delirium: Two months after he was initially seen by psychiatry, Mr. J underwent bilateral lung transplantation. Postoperatively, he became confused, disoriented, and paranoid. He believed that his hand was cut off and that his nurse was trying to kill him and remove his organs. Extreme restlessness necessitated soft restraints. Haloperidol was added for treatment of delirium, which subsided within a week. Subsequently, guanfacine and haloperidol were tapered off, and he was discharged one month after his transplantation.

Acute stress disorder/posttraumatic stress disorder related to transplant (PTSD-T): During outpatient follow-up a week after discharge, Mr. J shared experiencing haunting images dating back to his delirium experiences. He avoided certain shows on TV that made him feel claustrophobic. He thought of future hospitalizations with terror. He initially declined required bronchoscopy due to his new fears and anxiety, but he was able to complete this procedure with psychological support from psychiatry and pretreatment with lorazepam before the procedure.

Posttransplant depression: Two months after his transplant, Mr. J felt depressed and hopeless and had decreased enjoyment of any activity. In fact, he wished at times he had not elected lung transplant. His mirtazapine was increased and bupropion started while psychotherapy continued. Within several months, his depression subsided, procedures became easier, and he eventually had resolution of PTSD-related flashbacks.

Discussion: This case highlights the scope and important role that C-L psychiatrists play in patients’ transplant journey. Anxiety is common in patients awaiting lung transplantation, due to a combination of physiological changes (that is, hypercapnia, hypoxemia) and psychological/existential reactions to the transplant experience. Data suggest that almost 40 percent of patients undergoing lung transplant evaluation have an anxiety disorder. While anxiety disorders are typically not a contraindication to transplantation, they can have significant impact on the transplant course, and effective interventions from the transplant psychiatrist can facilitate the process. When treating this medically vulnerable population, psychiatrists need to have expertise in selecting efficacious psychiatric treatments, while also mitigating potential adverse effects of psychotropic agents and drug interactions. For example, benzodiazepines are often avoided in the peritransplant period due to risks of respiratory depression and cognitive side effects. Therefore, Mr. J was treated with a combination of mirtazapine, gabapentin, and guanfacine to avoid use of benzodiazepines for his anxiety.