- Email: [email protected]
Liver Transplantation and the Alcoholic Patient: Medical, Surgical, and Psychosocial Issues
Book Reviews DONNA B. GREENBERG, M.D. BOOK REVIEW EDITOR
Liver Transplantation and the Alcoholic Patient: Medical, Surgical, and Psychosocial Issues By Michael R. Lucey, Robert M. Merion, and Thomas Beresford New York, Cambridge University Press, 1994 134 pages, ISBN 0-521-43332-0, $49.95 Reviewed by Donna B. Greenberg. M.D.
A
lcohol-induced liver disease is the most common cause of liver failure. Thus far, the outcome of liver transplantation in rigorously selected alcoholic candidates does not differ from the outcome of other patients. Poor prognosis for abstinence is a relative contraindication to transplantation. However, some advocate further that alcoholics with end-stage liver disease should undergo a more stringent process of candidate selection for liver transplant than nonalcoholic patients. The charged issues of personal responsibility, psychiatric and medical uncertainty, and limited health resources heighten the importance of this specific medical predicament. Drawing from their experience at the University of Michigan Medical Center, the authors of this concise monograph review evaluation, surgery, and posttransplant care for alcoholic patients who want liver transplantation for alcohol-induced liver disease. Overt and covert alcoholism, psychiatric and medical assessment. outcome, psychiatric follow-up care, and ethics are the monograph's major topics. In their program. actuarial patient survival for 90 alcoholic recipients is 73% and 69%, respectively. compared with 73% and 67% for nonalcoholic recipients. Beresford's discussion of psychiatric assessment is the most critical chapter. How does the clinician judge whether the patient will refrain VOLUME 35' NUMBER 5' SEPTEMBER - OCTOBER 1994
from drinking after surgery? The drinking history is not merely a matter of denying or acknowledging alcoholism. The relationship with alcohol is often intensely ambivalent. Drinking behavior. Beresford notes, is never static. He recommends that patients be seen at different times by different observers. Negative prognostic factors: preexisting psychotic disorder, unstable character disorder. unremitted poly drug abuse, multiple alcohol rehabilitation attempts. and social isolation are weighed against subtle assessment of Valliant's positive prognostic factors: structured activities not linked to drinking, a relationship with a person who signals unambivalent belief in the person, a source of hope or renewed self-esteem, and an immediate negative consequence of drinking (e.g., pain or jail). In this program, I in 6 (16%) were excluded for psychosocial reasons. He notes that Valliant's factors alone would have ruled out I in 10. While many transplant centers require a time of abstinence before transplant, it is not clear that the duration of sobriety predicts postoperative sobriety. Outcome data is limited. Rather than a written pledge of sobriety, Beresford favors regular follow-up visits to assess motivation and abstinence. This signals a continuing commitment. The chapter on ethics by Benjamin and Turcotte evaluates the responsibility of alcoholic patients for their illness, whether this should be a consideration in determining access to livers, or whether by more careful selection, abstinent alcoholic patients may have the same opportunity as other medically suitable patients who are not alcoholic. They examine the arguments that patients with alcohol-induced liver disease should have a lower priority, should compete equally, or that there be a compromise between these positions. In the discussion of medical aspects, Lucey 501
Book Reviews
describes the difficulties of knowing in some cases whether the disease is directly attributable to alcohol. Sometimes fixed cerebral defects cannot be distinguished from chronic encephalopathy. Sometimes the cognitive impairment of hepatic encephalopathy is misread. Patients who may not be able to learn and remember are referred for rehabilitation. Lucey and colleagues' contribution is a thoughtful. clinically based report with outcome data and nuts-and-bolts wisdom that contributes to the literature and to our clinical expertise. Dr. Greenhcrg is associate psychiatrist at Massachusells General Hospital. and assistant professor of psychiatry. Harvard Medical School. Boston. MA.
Diagnosis and Treatment of Depression in Late Life: Results of the NIH Consensus Development Conference Edited by Lon S. Schneider. Charles F. Reynolds III. Barry Lebovitz. and Arnold J. Friedhoff Washington. DC. American Psychiatric Press. 1994 535 pages. ISBN 0--88048-556-6. $46.50 Reviewed by M. Comelia Cremens. M.D.
D
iagllosis lIlId Treatmellt
{)f
Depressioll ill
Late L(fe is an impressive undertaking. The
editors gathered together experts in this field to pool their clinical and research experience. The book is divided into seven sections. In the first section. the introduction. Reynolds briefly outlines the major considerations in the diagnosis and treatment of depression in late life as reviewed by the National Institutes of Health (NIH) panel of experts chaired by Alfred J. Freidhoff. M.D. (Chapter 26). Six questions formulated by the NIH planning committee and later incorporated in the Consensus Development Conference Statement include the epidemiological and phenomenological heterogeneity of depressive illness in late life; biological and psychosocial factors in pathogenesis; and the in5112
dication for the available psychotherapies and somatic therapies in both the acute and long-term management of depression. Blazer discusses the epidemiology as reflected in the recent literature with a succinct outline of prevalence. bias and cohort effect in his concluding remarks. The epidemiology of depression in late life is controversial. Section Two organizes three chapters around the phenomenology. clinical heterogeneity. and course of late-life depression. Caine and colleagues undertake the heterogeneity of mood disorders with a heroic effort in view of the limitations of the available studies. Important is their message to broaden the scope of depression and include the various presentations of psychiatric illness in the elderly. Reifler. in Chapter 4. focuses on the diagnosis and comorbidity of depression. more frequent in the elderly population. by dispelling two common myths: I) that depressive symptoms accompany aging. and 2) that disabling illness leads to major depression. The coexistence of depression and dementia or disabling illness is additive in the functional decline of the older person. The following chapter continues the theme of functional decline and delves into the quality of life for the older adult. Quality of life is presented by Gurland with a perspective that stresses the capacity of the elderly to enhance their life with successful management of a treatable illness. Murphy addresses the looming question of prognosis and outcome. confirming the evidence in the literature of a high incidence of relapse. He suggests aggressive treatment. frequent review of symptoms. and generous use of medications as prophylaxis. Section III focuses on the biological and psychosocial factors. Alexopoulos' s chapter provides a concise summary of the biological markers related to depression in the older patient. However. no biological marker has proved clinically reliable as a diagnostic tool. Future research efforts in monoamine and monoaminerelated enzymes and the relationship between functional and structural abnormalities in the advent of more powerful imaging techniques were suggested in his conclusion. The structural and functional correlates in the elderly brain are PSYCHOSOMATICS
Liver Transplantation and the Alcoholic Patient: Medical, Surgical, and Psychosocial Issues By Michael R. Lucey, Robert M. Merion, and Thomas Beresford New York, Cambridge University Press, 1994 134 pages, ISBN 0-521-43332-0, $49.95 Reviewed by Donna B. Greenberg. M.D.
A
lcohol-induced liver disease is the most common cause of liver failure. Thus far, the outcome of liver transplantation in rigorously selected alcoholic candidates does not differ from the outcome of other patients. Poor prognosis for abstinence is a relative contraindication to transplantation. However, some advocate further that alcoholics with end-stage liver disease should undergo a more stringent process of candidate selection for liver transplant than nonalcoholic patients. The charged issues of personal responsibility, psychiatric and medical uncertainty, and limited health resources heighten the importance of this specific medical predicament. Drawing from their experience at the University of Michigan Medical Center, the authors of this concise monograph review evaluation, surgery, and posttransplant care for alcoholic patients who want liver transplantation for alcohol-induced liver disease. Overt and covert alcoholism, psychiatric and medical assessment. outcome, psychiatric follow-up care, and ethics are the monograph's major topics. In their program. actuarial patient survival for 90 alcoholic recipients is 73% and 69%, respectively. compared with 73% and 67% for nonalcoholic recipients. Beresford's discussion of psychiatric assessment is the most critical chapter. How does the clinician judge whether the patient will refrain VOLUME 35' NUMBER 5' SEPTEMBER - OCTOBER 1994
from drinking after surgery? The drinking history is not merely a matter of denying or acknowledging alcoholism. The relationship with alcohol is often intensely ambivalent. Drinking behavior. Beresford notes, is never static. He recommends that patients be seen at different times by different observers. Negative prognostic factors: preexisting psychotic disorder, unstable character disorder. unremitted poly drug abuse, multiple alcohol rehabilitation attempts. and social isolation are weighed against subtle assessment of Valliant's positive prognostic factors: structured activities not linked to drinking, a relationship with a person who signals unambivalent belief in the person, a source of hope or renewed self-esteem, and an immediate negative consequence of drinking (e.g., pain or jail). In this program, I in 6 (16%) were excluded for psychosocial reasons. He notes that Valliant's factors alone would have ruled out I in 10. While many transplant centers require a time of abstinence before transplant, it is not clear that the duration of sobriety predicts postoperative sobriety. Outcome data is limited. Rather than a written pledge of sobriety, Beresford favors regular follow-up visits to assess motivation and abstinence. This signals a continuing commitment. The chapter on ethics by Benjamin and Turcotte evaluates the responsibility of alcoholic patients for their illness, whether this should be a consideration in determining access to livers, or whether by more careful selection, abstinent alcoholic patients may have the same opportunity as other medically suitable patients who are not alcoholic. They examine the arguments that patients with alcohol-induced liver disease should have a lower priority, should compete equally, or that there be a compromise between these positions. In the discussion of medical aspects, Lucey 501
Book Reviews
describes the difficulties of knowing in some cases whether the disease is directly attributable to alcohol. Sometimes fixed cerebral defects cannot be distinguished from chronic encephalopathy. Sometimes the cognitive impairment of hepatic encephalopathy is misread. Patients who may not be able to learn and remember are referred for rehabilitation. Lucey and colleagues' contribution is a thoughtful. clinically based report with outcome data and nuts-and-bolts wisdom that contributes to the literature and to our clinical expertise. Dr. Greenhcrg is associate psychiatrist at Massachusells General Hospital. and assistant professor of psychiatry. Harvard Medical School. Boston. MA.
Diagnosis and Treatment of Depression in Late Life: Results of the NIH Consensus Development Conference Edited by Lon S. Schneider. Charles F. Reynolds III. Barry Lebovitz. and Arnold J. Friedhoff Washington. DC. American Psychiatric Press. 1994 535 pages. ISBN 0--88048-556-6. $46.50 Reviewed by M. Comelia Cremens. M.D.
D
iagllosis lIlId Treatmellt
{)f
Depressioll ill
Late L(fe is an impressive undertaking. The
editors gathered together experts in this field to pool their clinical and research experience. The book is divided into seven sections. In the first section. the introduction. Reynolds briefly outlines the major considerations in the diagnosis and treatment of depression in late life as reviewed by the National Institutes of Health (NIH) panel of experts chaired by Alfred J. Freidhoff. M.D. (Chapter 26). Six questions formulated by the NIH planning committee and later incorporated in the Consensus Development Conference Statement include the epidemiological and phenomenological heterogeneity of depressive illness in late life; biological and psychosocial factors in pathogenesis; and the in5112
dication for the available psychotherapies and somatic therapies in both the acute and long-term management of depression. Blazer discusses the epidemiology as reflected in the recent literature with a succinct outline of prevalence. bias and cohort effect in his concluding remarks. The epidemiology of depression in late life is controversial. Section Two organizes three chapters around the phenomenology. clinical heterogeneity. and course of late-life depression. Caine and colleagues undertake the heterogeneity of mood disorders with a heroic effort in view of the limitations of the available studies. Important is their message to broaden the scope of depression and include the various presentations of psychiatric illness in the elderly. Reifler. in Chapter 4. focuses on the diagnosis and comorbidity of depression. more frequent in the elderly population. by dispelling two common myths: I) that depressive symptoms accompany aging. and 2) that disabling illness leads to major depression. The coexistence of depression and dementia or disabling illness is additive in the functional decline of the older person. The following chapter continues the theme of functional decline and delves into the quality of life for the older adult. Quality of life is presented by Gurland with a perspective that stresses the capacity of the elderly to enhance their life with successful management of a treatable illness. Murphy addresses the looming question of prognosis and outcome. confirming the evidence in the literature of a high incidence of relapse. He suggests aggressive treatment. frequent review of symptoms. and generous use of medications as prophylaxis. Section III focuses on the biological and psychosocial factors. Alexopoulos' s chapter provides a concise summary of the biological markers related to depression in the older patient. However. no biological marker has proved clinically reliable as a diagnostic tool. Future research efforts in monoamine and monoaminerelated enzymes and the relationship between functional and structural abnormalities in the advent of more powerful imaging techniques were suggested in his conclusion. The structural and functional correlates in the elderly brain are PSYCHOSOMATICS