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Psychiatric morbidity in patients undergoing heart, heart and lung, or lung transplantation
Journal of Psychosomatic Research 50 (2001) 103 ± 105
Short communication
Psychiatric morbidity in patients undergoing heart, heart and lung, or lung transplantation Anne Trumper, Louis Appleby* School of Psychiatry and Behavioural Sciences, Withington Hospital, University of Manchester, Nell Lane, West Didsbury, Manchester M20 8LR, UK Received 13 December 1999; accepted 16 May 2000
Abstract Objectives: To determine the rate of psychiatric disorder in people undergoing heart and/or lung transplantation; to identify the associations of psychiatric disorder in this group. Method: Preoperative assessments were carried out on an 18-month sample of consecutive admissions to a regional unit for heart and lung transplantation in the UK. Assessment included psychiatric morbidity, sexual dysfunction, quality of life, and demographic and clinical characteristics. Results: Seventy-six of 79 eligible subjects took part in the assessment. Thirty (39%) were suffering from a psychiatric disorder, the most common being major depressive disorder. Forty-four (58%) reported sexual dysfunction.
Clinically significant psychiatric morbidity was associated with a history of treatment for mental disorder, unemployment, and length of physical illness. Patients with psychiatric disorder reported poorer quality of life on the SF-36, with lower scores on subscales for general health perception, social functioning, and energy/ vitality. Conclusion: There is a substantial rate of psychiatric disorder in people undergoing heart and/or lung transplantation. Risk is higher in people with a history of psychiatric vulnerability and current illness-related factors. Preoperative psychiatric assessment and intervention in some patients may be a valuable part of their clinical care. D 2001 Elsevier Science Inc. All rights reserved.
Keywords: Psychiatric morbidity; Transplantation; Predictors; Quality of life
Introduction The transplantation of heart, lung, or heart and lung combined, is a potentially life-saving treatment for people with terminal cardiac or respiratory disease. The operation is also itself life-threatening, both preoperative and postoperative treatments are intensive and patients require close perioperative monitoring. In recognition of the stresses that face transplantation patients, a number of centers now offer preoperative counseling, though the effectiveness of this intervention has not been evaluated. Rates of anxiety and depression of around 50% have been found in previous studies of psychiatric morbidity in preoperative cardiac transplant patients [1 ± 4], psychiatric disorder being seen as secondary to physical illness [5]. These studies were of North American patients; rates in other countries, including the United Kingdom, may be
* Corresponding author. Tel.: +44-161-291-4362; fax: +44-161-4459263. E-mail address: [email protected] (L. Appleby).
different because of differences in the criteria for transplantation. Such preoperative psychiatric morbidity is important as it may influence the outcome of surgery, for example, by affecting compliance with follow-up and drug treatment, and as it is likely to be treatable in many cases. The aims of this study were (1) to measure the prevalence of clinically significant depression and anxiety in patients admitted to hospital for assessment for heart and/or lung transplantation, (2) to determine the demographic and clinical associations of psychiatric morbidity, and (3) to examine the association between psychiatric morbidity and aspects of quality of life preoperatively. Method Subjects An 18-month sample of consecutive inpatients undergoing assessment for heart and/or lung transplantation at the Regional Transplant Unit, Wythenshawe Hospital, Manchester, was asked to take part in the study. Exclusion criteria
0022-3999/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 0 ) 0 0 2 1 4 - 2
104
A. Trumper, L. Appleby / Journal of Psychosomatic Research 50 (2001) 103±105
Table 1 Comparison of cases and noncases of psychiatric disorder: demographic and clinical variables Age (year): median (range) Male sex: no. (%) Past psychiatric history: no. (%) Unmarried: no. (%) Unemployment: no. (%) Length of illness (months): median (range) a b
Cases (n = 30)
Noncases (n = 46)
P values
52 21 10 22 18 60
51 34 5 39 15 36
.71a .80b .02b .35b .03b .05a
(17 ± 61) (70%) (33%) (74%) (60%) (5 ± 360)
(24 ± 64) (74%) (11%) (85%) (33%) (3 ± 336)
Mann ± Whitney U test. Chi-square test.
were: age less than 16 years, admission as an emergency, and being too ill to complete the assessment. Assessment (1) Mood was assessed using the revised clinical interview schedule (CISR) [6]. This instrument is designed to measure nonpsychotic psychiatric morbidity in general hospital and community samples; a score of 12 or above indicates clinically significant disorder. In this study, questions were added to allow a diagnosis to be made according to DSMIII-R. (2) Sexual dysfunction was identified from patient report at interview. (3) Current alcohol intake was recorded in units from patient report at interview. (4) The following demographic and clinical variables were recorded: age, gender, employment, length of illness, and past psychiatric history (defined as treatment for any psychiatric disorder by a general practitioner or mental health professional). (5) Quality of life was assessed using the SF-36 health status questionnaire [7]. This instrument leads to scores on nine subscales, based on patient report. Ethical approval was obtained for the study. All patients gave informed consent. Statistical analysis Cases, i.e., those with psychiatric disorder, and noncases were compared using chi-square tests for categorical data and Mann ± Whitney U tests for continuous variables.
Results There were 79 eligible patients during the 18-month study period. Three others were excluded because of severe physical illness. Three refused to take part or withdrew before completing the assessment. The findings below therefore refer to the remaining 76 patients, 96% of those who were eligible, of whom 55 (72%) were male. Thirty-seven patients were being assessed for heart transplantation, 37 for lung transplantation, and two for transplantation of both heart and lung. Fourteen had been ill for less than 1 year, but most had been ill for many years, some since childhood. Thirty-three (43%) were not working because of physical illness. Psychiatric morbidity Thirty patients (39%) were suffering from clinically significant psychiatric disorder; 22 cases of major depressive disorder, eight of generalized anxiety disorder. Forty-four (58%) reported sexual dysfunction (erectile dysfunction, loss of libido or physical limitation), of whom 36 (82%) were male. Four patients (three males, one female) reported drinking alcohol above the levels of 21 units per week (males) or 14 units per week (females). Table 1 shows the associations of psychiatric morbidity. There were associations with previous psychiatric history, unemployment, and length of illness. Table 2 shows scores on the subscales of the SF-36 in cases and noncases. Patients with clinically significant psychiatric disorder reported poorer mental health and greater ``role limitation due to emotional disorder.'' Psychiatric disorder was asso-
Table 2 Comparison of cases and noncases of psychiatric disorder: median scores (range) on quality of life subscales (SF-36)
Physical functioning Bodily pain Energy/vitality Role limitation due to physical disorder Social functioning General mental health Role limitation due to emotional disorder General health perception Change in health
Cases (n = 30)
Noncases (n = 46)
Mann ± Whitney U test P value
5 50 15 0 22 60 0 8 0
10 67 30 0 33 72 67 20 0
.31 .36 .08 .28 .06 .01 .09 .03 .44
(0 ± 90) (0 ± 100) (0 ± 65) (0 ± 100) (0 ± 78) (0 ± 88) (0 ± 100) (0 ± 78) (0 ± 75)
(0 ± 85) (0 ± 100) (0 ± 100) (0 ± 100) (0 ± 100) (0 ± 96) (0 ± 100) (0 ± 72) (0 ± 100)
A. Trumper, L. Appleby / Journal of Psychosomatic Research 50 (2001) 103±105
ciated with poorer ``general health perception'' but not with actual physical limitation, and there were borderline associations with poorer social functioning and lower energy/ vitality. Role limitation due to physical disorder was severe in both cases and noncases.
105
whether improvements in postoperative physical health, quality of life, or compliance can be achieved by preoperative treatment. Acknowledgments
Discussion The main finding of this study is a prevalence of psychiatric morbidity of 39% in patients undergoing assessment for heart and/or lung transplantation in a regional unit. This is lower than some previous North American studies have reported, though one US study also found a figure of 39% [8]. Psychiatric morbidity was associated with two ``illness-related'' variables, i.e., duration of illness and unemployment, and was more common in people with a history of treatment for mental disorder. Patients' reports of some aspects of their quality of life were worse in those with psychiatric disorder; for example, they perceived their general health to be poorer. In the total sample, there was a high rate of reported sexual dysfunction. Certain methodological limitations of this study should be emphasized. Information was obtained by patient report without confirmation from other sources. Sexual dysfunction was assessed by clinical interview alone. The relationship between psychiatric morbidity and the significant variables may not be causal; for example, variables such as unemployment may contribute to psychiatric disorder or be a consequence of it. Overall, the results highlight the psychological needs of transplant patients and appear to justify preoperative psychiatric assessment of emotional disorders in this group. However, it is not yet known whether preoperative psychiatric disorder predicts the postoperative outcome or
The authors would like to thank the clinical staff of the Regional Transplant Unit at Wythenshawe Hospital for their cooperation in conducting this study. These findings form the basis of an MSc thesis submitted by Dr. Trumper to the University of Manchester. References [1] Mai FM, McKenzie FN, Kostuk WJ. Liaison psychiatric in the heart transplant unit. Psychosom Res 1984;45:80 ± 1. [2] Mai FM, McKenzie FN, Kostuk WJ. Psychiatric aspects of heart transplantation: preoperative evaluation and postoperative sequelae. Br Med J 1986;292:311 ± 3. [3] Kuhn WF, Myers B, Brennan AF, Davies MH, Lippmann SB, Gray LA, Pool GE. Psychopathology in heart transplant candidates. J Heart Transplant 1988;7:223 ± 6. [4] Jones BM, Chang VP, Esmore D, Spratt P, Shanahan MX, Farnsworth AE, Keogh A, Downs K. Psychological adjustment after cardiac transplantation. Med J Aust 1988;149:118 ± 22. [5] Mai FM. Psychiatric aspects of heart transplantation. Br J Psychiatry 1993;163:285 ± 92. [6] Lewis G, Pelosi AJ, Araya R, Dunn G. Measuring psychiatric disorder in the community: a standardised assessment for use by lay interviewers. Psychol Med 1992;22:465 ± 86. [7] Brazier JE, Harper R, Jones NMB, O'Cathain A, Thomas KJ, Usherwood T, Westlake L. Validating the SF-36 health survey questionnaire: a new outcome measure for primary care. Br Med J 1992;305:160 ± 4. [8] Freeman AM, Folks DG, Sokol RS, Fahs JJ. Cardiac transplantation: clinical correlates of psychiatric outcome. Psychosomatics 1988;29: 47 ± 54.
Short communication
Psychiatric morbidity in patients undergoing heart, heart and lung, or lung transplantation Anne Trumper, Louis Appleby* School of Psychiatry and Behavioural Sciences, Withington Hospital, University of Manchester, Nell Lane, West Didsbury, Manchester M20 8LR, UK Received 13 December 1999; accepted 16 May 2000
Abstract Objectives: To determine the rate of psychiatric disorder in people undergoing heart and/or lung transplantation; to identify the associations of psychiatric disorder in this group. Method: Preoperative assessments were carried out on an 18-month sample of consecutive admissions to a regional unit for heart and lung transplantation in the UK. Assessment included psychiatric morbidity, sexual dysfunction, quality of life, and demographic and clinical characteristics. Results: Seventy-six of 79 eligible subjects took part in the assessment. Thirty (39%) were suffering from a psychiatric disorder, the most common being major depressive disorder. Forty-four (58%) reported sexual dysfunction.
Clinically significant psychiatric morbidity was associated with a history of treatment for mental disorder, unemployment, and length of physical illness. Patients with psychiatric disorder reported poorer quality of life on the SF-36, with lower scores on subscales for general health perception, social functioning, and energy/ vitality. Conclusion: There is a substantial rate of psychiatric disorder in people undergoing heart and/or lung transplantation. Risk is higher in people with a history of psychiatric vulnerability and current illness-related factors. Preoperative psychiatric assessment and intervention in some patients may be a valuable part of their clinical care. D 2001 Elsevier Science Inc. All rights reserved.
Keywords: Psychiatric morbidity; Transplantation; Predictors; Quality of life
Introduction The transplantation of heart, lung, or heart and lung combined, is a potentially life-saving treatment for people with terminal cardiac or respiratory disease. The operation is also itself life-threatening, both preoperative and postoperative treatments are intensive and patients require close perioperative monitoring. In recognition of the stresses that face transplantation patients, a number of centers now offer preoperative counseling, though the effectiveness of this intervention has not been evaluated. Rates of anxiety and depression of around 50% have been found in previous studies of psychiatric morbidity in preoperative cardiac transplant patients [1 ± 4], psychiatric disorder being seen as secondary to physical illness [5]. These studies were of North American patients; rates in other countries, including the United Kingdom, may be
* Corresponding author. Tel.: +44-161-291-4362; fax: +44-161-4459263. E-mail address: [email protected] (L. Appleby).
different because of differences in the criteria for transplantation. Such preoperative psychiatric morbidity is important as it may influence the outcome of surgery, for example, by affecting compliance with follow-up and drug treatment, and as it is likely to be treatable in many cases. The aims of this study were (1) to measure the prevalence of clinically significant depression and anxiety in patients admitted to hospital for assessment for heart and/or lung transplantation, (2) to determine the demographic and clinical associations of psychiatric morbidity, and (3) to examine the association between psychiatric morbidity and aspects of quality of life preoperatively. Method Subjects An 18-month sample of consecutive inpatients undergoing assessment for heart and/or lung transplantation at the Regional Transplant Unit, Wythenshawe Hospital, Manchester, was asked to take part in the study. Exclusion criteria
0022-3999/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 0 ) 0 0 2 1 4 - 2
104
A. Trumper, L. Appleby / Journal of Psychosomatic Research 50 (2001) 103±105
Table 1 Comparison of cases and noncases of psychiatric disorder: demographic and clinical variables Age (year): median (range) Male sex: no. (%) Past psychiatric history: no. (%) Unmarried: no. (%) Unemployment: no. (%) Length of illness (months): median (range) a b
Cases (n = 30)
Noncases (n = 46)
P values
52 21 10 22 18 60
51 34 5 39 15 36
.71a .80b .02b .35b .03b .05a
(17 ± 61) (70%) (33%) (74%) (60%) (5 ± 360)
(24 ± 64) (74%) (11%) (85%) (33%) (3 ± 336)
Mann ± Whitney U test. Chi-square test.
were: age less than 16 years, admission as an emergency, and being too ill to complete the assessment. Assessment (1) Mood was assessed using the revised clinical interview schedule (CISR) [6]. This instrument is designed to measure nonpsychotic psychiatric morbidity in general hospital and community samples; a score of 12 or above indicates clinically significant disorder. In this study, questions were added to allow a diagnosis to be made according to DSMIII-R. (2) Sexual dysfunction was identified from patient report at interview. (3) Current alcohol intake was recorded in units from patient report at interview. (4) The following demographic and clinical variables were recorded: age, gender, employment, length of illness, and past psychiatric history (defined as treatment for any psychiatric disorder by a general practitioner or mental health professional). (5) Quality of life was assessed using the SF-36 health status questionnaire [7]. This instrument leads to scores on nine subscales, based on patient report. Ethical approval was obtained for the study. All patients gave informed consent. Statistical analysis Cases, i.e., those with psychiatric disorder, and noncases were compared using chi-square tests for categorical data and Mann ± Whitney U tests for continuous variables.
Results There were 79 eligible patients during the 18-month study period. Three others were excluded because of severe physical illness. Three refused to take part or withdrew before completing the assessment. The findings below therefore refer to the remaining 76 patients, 96% of those who were eligible, of whom 55 (72%) were male. Thirty-seven patients were being assessed for heart transplantation, 37 for lung transplantation, and two for transplantation of both heart and lung. Fourteen had been ill for less than 1 year, but most had been ill for many years, some since childhood. Thirty-three (43%) were not working because of physical illness. Psychiatric morbidity Thirty patients (39%) were suffering from clinically significant psychiatric disorder; 22 cases of major depressive disorder, eight of generalized anxiety disorder. Forty-four (58%) reported sexual dysfunction (erectile dysfunction, loss of libido or physical limitation), of whom 36 (82%) were male. Four patients (three males, one female) reported drinking alcohol above the levels of 21 units per week (males) or 14 units per week (females). Table 1 shows the associations of psychiatric morbidity. There were associations with previous psychiatric history, unemployment, and length of illness. Table 2 shows scores on the subscales of the SF-36 in cases and noncases. Patients with clinically significant psychiatric disorder reported poorer mental health and greater ``role limitation due to emotional disorder.'' Psychiatric disorder was asso-
Table 2 Comparison of cases and noncases of psychiatric disorder: median scores (range) on quality of life subscales (SF-36)
Physical functioning Bodily pain Energy/vitality Role limitation due to physical disorder Social functioning General mental health Role limitation due to emotional disorder General health perception Change in health
Cases (n = 30)
Noncases (n = 46)
Mann ± Whitney U test P value
5 50 15 0 22 60 0 8 0
10 67 30 0 33 72 67 20 0
.31 .36 .08 .28 .06 .01 .09 .03 .44
(0 ± 90) (0 ± 100) (0 ± 65) (0 ± 100) (0 ± 78) (0 ± 88) (0 ± 100) (0 ± 78) (0 ± 75)
(0 ± 85) (0 ± 100) (0 ± 100) (0 ± 100) (0 ± 100) (0 ± 96) (0 ± 100) (0 ± 72) (0 ± 100)
A. Trumper, L. Appleby / Journal of Psychosomatic Research 50 (2001) 103±105
ciated with poorer ``general health perception'' but not with actual physical limitation, and there were borderline associations with poorer social functioning and lower energy/ vitality. Role limitation due to physical disorder was severe in both cases and noncases.
105
whether improvements in postoperative physical health, quality of life, or compliance can be achieved by preoperative treatment. Acknowledgments
Discussion The main finding of this study is a prevalence of psychiatric morbidity of 39% in patients undergoing assessment for heart and/or lung transplantation in a regional unit. This is lower than some previous North American studies have reported, though one US study also found a figure of 39% [8]. Psychiatric morbidity was associated with two ``illness-related'' variables, i.e., duration of illness and unemployment, and was more common in people with a history of treatment for mental disorder. Patients' reports of some aspects of their quality of life were worse in those with psychiatric disorder; for example, they perceived their general health to be poorer. In the total sample, there was a high rate of reported sexual dysfunction. Certain methodological limitations of this study should be emphasized. Information was obtained by patient report without confirmation from other sources. Sexual dysfunction was assessed by clinical interview alone. The relationship between psychiatric morbidity and the significant variables may not be causal; for example, variables such as unemployment may contribute to psychiatric disorder or be a consequence of it. Overall, the results highlight the psychological needs of transplant patients and appear to justify preoperative psychiatric assessment of emotional disorders in this group. However, it is not yet known whether preoperative psychiatric disorder predicts the postoperative outcome or
The authors would like to thank the clinical staff of the Regional Transplant Unit at Wythenshawe Hospital for their cooperation in conducting this study. These findings form the basis of an MSc thesis submitted by Dr. Trumper to the University of Manchester. References [1] Mai FM, McKenzie FN, Kostuk WJ. Liaison psychiatric in the heart transplant unit. Psychosom Res 1984;45:80 ± 1. [2] Mai FM, McKenzie FN, Kostuk WJ. Psychiatric aspects of heart transplantation: preoperative evaluation and postoperative sequelae. Br Med J 1986;292:311 ± 3. [3] Kuhn WF, Myers B, Brennan AF, Davies MH, Lippmann SB, Gray LA, Pool GE. Psychopathology in heart transplant candidates. J Heart Transplant 1988;7:223 ± 6. [4] Jones BM, Chang VP, Esmore D, Spratt P, Shanahan MX, Farnsworth AE, Keogh A, Downs K. Psychological adjustment after cardiac transplantation. Med J Aust 1988;149:118 ± 22. [5] Mai FM. Psychiatric aspects of heart transplantation. Br J Psychiatry 1993;163:285 ± 92. [6] Lewis G, Pelosi AJ, Araya R, Dunn G. Measuring psychiatric disorder in the community: a standardised assessment for use by lay interviewers. Psychol Med 1992;22:465 ± 86. [7] Brazier JE, Harper R, Jones NMB, O'Cathain A, Thomas KJ, Usherwood T, Westlake L. Validating the SF-36 health survey questionnaire: a new outcome measure for primary care. Br Med J 1992;305:160 ± 4. [8] Freeman AM, Folks DG, Sokol RS, Fahs JJ. Cardiac transplantation: clinical correlates of psychiatric outcome. Psychosomatics 1988;29: 47 ± 54.