How Critical Is Mental Health in Transplant Decisions?

The major motivation for transplanting a kidney from a healthy donor to a patient in kidney failure is to improve the patient's well-being. But does simply transplanting the organ necessarily achieve that end point?

Researchers at the Ohio State University Medical Center and at Ashland University in Ohio believe too little attention has been paid to other factors, particularly the mental health of transplant recipients.

"Despite the fact that kidney transplants have been performed for over 40 years, the study of psychosocial factors in transplantation has only really been examined over the past 15 to 20 years by a small number of researchers," said Kristin Kuntz, Ph.D., a clinical assistant professor of psychiatry and the transplant psychologist for the Ohio State University Comprehensive Transplant Center.

"For years, the medical community has focused on medical and surgical barriers to transplant, and they have maybe dismissed depression and anxiety as a byproduct of living with a chronic illness. Of course, some patients may meet criteria for an adjustment disorder, and their symptoms may resolve once they feel better physically. But for those who have a longstanding history of psychological distress, continued distress after transplant can lead to poorer medical outcomes," she told Psychiatric News.

Kuntz and co-researcher Diane Bonfiglio, in a report published in the online Journal of Clinical Psychology in Medical Settings in June, examined rates of psychological distress experienced by renal-transplant candidates using the Patient Health Questionnaire (PHQ) in a sample of 518 end-stage renal-disease patients at the point of first contact with the transplant center. In this sample, 15.1 percent of patients indicated symptoms consistent with a depressive condition, and 7.6 percent had symptoms consistent with an anxiety disorder.

"Patients present to the transplant clinic in many cases after years of living with kidney disease and facing the challenges of chronic illness, which can lead to poor quality of life and depression. Transplantation may feel to them like their only hope of having an improved quality of life (and longer life), so anxiety about whether they will be approved for transplant often ensues," said Kuntz.

The researchers expressed concern that the rates of psychiatric illness symptoms they detected were lower than expected. They cited a less distressed sample, selection biases, or underreporting of symptoms due to patients' motivation to present themselves positively as possible causes for the underreporting.

They also noted that the PHQ was developed for use in medical settings and is less likely than other assessment methods to confound psychological diagnosis with unrelated somatic complaints, such as symptoms of uremia—anorexia, lethargy, trouble sleeping, and decreased mental acuity—that kidney-failure patients can experience. "This quality of the PHQ may make it more likely to estimate psychological distress in a more conservative manner," they noted.

Kuntz explained why detecting mental health concerns in transplant candidates is so crucial: "In the early stages of evaluation, depression and anxiety can lead to problems with patients not showing up to appointments or not completing them in a timely manner. When psychological distress is identified early, we can help patients get the proper treatment to help them in coping successfully throughout the transplant process."

Kidney transplant recipient Michelle Buonfiglio agreed: "Identifying mental health issues in renal-disease patients might help with medication compliance, will possibly have a positive effect on the overall health of the patient, and might increase patient 'mental readiness' at the time of the transplant, leading to more successful posttransplant compliance and success," she told Psychiatric News (see From Disease to Transplant: a Very Personal Travelogue). "I think patients also have to be taught skills to cope with issues that will develop posttransplant, to help them overcome setbacks and obstacles more quickly as they heal."

The researchers offered advice to practitioners working with this patient population. "Patients should be informed that it is to their benefit to be honest about how they are coping during what can be a difficult time psychologically so they can be referred for appropriate treatment. Given that patients listed for kidney transplant may wait several years before receiving a transplant, there is time for them to pursue psychiatric treatment."