Suicide in Liver Transplant Patients

Case Reports Suicide in Liver Transplant Patients ANNE MARIE RIETHER, M.D. ELIZABETH MAHLER, M.D.

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iver transplant centers select potential transplant recipients. realizing that each recipient will use a tremendous amount of institutional resources and will require a lifetime commitment of ongoing medical monitoring and care. Further. each recipient will receive a scarce national resource. a viable liver. Psychiatric evaluation is. therefore. almost routine at most transplant centers for identifying actual and potential problems that may contraindicate transplant.! This evaluation seeks to identify patients at risk for psychiatric morbidity and mortality and documents a psychiatric baseline functioning for comparison with future assessments. Liver transplant candidates and recipients often experience some degree of depression. anxiety. fear. cognitive impairment. forced dependence. and an uncertain future with transplant.' Most. however. are not overwhelmed with depression.-' Although one might expect this population to be at high risk for suicide. most liver transplant candidates do not attempt suicide. Instead. most are optimistic about a better quality oflife aftertransplant. This expectation is important because hopelessness was predictive of suicide in up to 91 Iff of cases in a study reported by Beck et al.~ In other studies. hopelessness was found to be 1.3 times more important than depression for explaining suicidal ideation.~·t> Re.:eivcd July 23. 1993: revised Decemllcr 30. 1993: ac.:epted January 24. 1994. From the Depanment of Psy.:hiatry. Morehouse S.:hool of Medi.:ine. Atlanta. GA; and the Dcpanment of Psy.:hiatry and Behavioral Scien.:es. Stanford University Medi.:al Center. Stanford. CA. Address wrresponden.:e to Dr. Riether. Clini.:al Assistant Professor of Psy.:hiatry. 4 Conwurse Parkway. Suite 160. Atlanta. GA

3m2!!. Copyright iD 1994 The Academy of Psy.:hosomati.: Medi.:ille.

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Nevertheless. transplant programs here and abroad are beginning to report suicides after successful transplantation. In the Netherlands. three patients attempted suicide and one completed suicide after liver transplantation (Heyink J. personal communication. 1990). In Padova. Italy. a heart transplant recipient died after discontinuing immunosuppressive therapy.7 At the University Hospital in Wales. two patients exhibited suicidal behavior after bone marrow transplantation. and one patient completed suicide. x In the United States. two potential lung transplant patients committed suicide: one during the preoperative evaluation phase and one after the patient was rejected for transplantation because of medical contraindications (Schlitt OJ. personal communication. 1990). In a study oflong-term survival (25 years) after renal transplantation. Starzl reported that one patient committed suicide by carbon monoxide inhalation despite excellent long-term graft functioning. In this group of73 patients. two other patients died after stopping immunosuppressive therapy in what may have been "covert" suicides. Interestingly. two of the surviving patients discontinued all therapy more than 20 years ago and have maintained excellent renal function. 9 Mood disorders are present in at least 50% of all suicides. III Depressive symptoms in liver transplant candidates and recipients may manifest as major depression. organic mood disorder. dysthymia. or adjustment disorder.' However. the vegetative signs and symptoms of depression may be difficult to sort out in the cirrhotic patient or newly transplanted liver recipient.!' As many as 50% of all patients who commit suicide have coexisting medical illnesses.!l Liver transplant candidates have medical complicaPSYCHOSOMATICS

Case Reports

tions that force bodily changes, physical limitations, and fatigue. II After transplant there are possible rejection episodes, opportunistic infections, and adverse side effects from medications. 2 However, chronic illness alone is rarely responsible for completed suicide. 12 Psychosocial environment, characterological style, and biologic vulnerability are also pertinent. L' Patients may also feel hopeless because of financial stress, guilt from the negative impact of their disease on interpersonal relationships, loss of insurance coverage, inability to work, and disappointment when expectations are not met. The following four case summaries describe transplant patients who actively attempted or completed suicide or stopped their immunosuppressive therapy.

Case Reports Case 1. A 40-year-old man with a IO-year history of chronic active hepatitis and schizotypal personality disorder had an acute psychotic decompensation that responded to a brief psychiatric hospitalization and low-dose haloperidol prior to transplant. His psychiatric recovery was complete, and after several months of outpatient psychiatric care with good compliance and no further decompensations. he underwent liver transplantation. Three months after successful transplant he was found dead, lying face down in his bathtub with his left wrist slashed. A crumpled hospital bill for his transplant was found in his waste basket. He had been seen for routine medical follow-up the week of his suicide and was doing well and did not appear depressed or psychotic. Case 2. A 37-year-old woman with chronic active hepatitis C. dysthymia. and borderline personality disorder was previously hospitalized twice for depression and had a family history of depression (mother) and suicide (sister). She had no history of substance abuse but an unstable social situation included three divorces. She was currently living with an alcoholic boyfriend. Although initially rejected as a candidate because of psychiatric instability. she was eventually transplanted because of deteriorating health. good medical compliance. attendance at a psychiatric support group, and fairly stable functioning. Postoperatively. she had acute medical compliVOLUME _,5 • NUMBER (, • NOVEMBER - DECEMBER 1994

cations. including rejection and a cytomegalovirus infection. During this time, her l6-year-old son was committed to a state mental hospital for cocaine abuse and suicidal ideation. Two months after transplant, the patient was readmitted with acute rejection. complaining about the side effects from immunosuppressive therapy. She was depressed but refused psychiatric intervention. Eight months after transplant, she attempted suicide by overdose of her antihypertensive medication and was committed to the psychiatric unit. She admitted she had also contemplated stopping her cyclosporine. After discharge. she refused to continue outpatient psychiatric care or any psychotropic medication. Twentyfive months after her transplant she was readmitted with acute liver failure. which progressed to multiorgan failure despite treatment. She died 25 months after transplant. It was rumored that she had stopped taking her prednisone because of cushingoid features. In the preceding year, the patient had been hospitalized six times for treatment of medical complications, including rejection, but consistently refused any ongoing psychiatric intervention. Case 3. A 20-year-old man with sclerosing cholangitis had no prior psychiatric history or diagnosis and limited support from a drug-addicted mother. He had a good history of compliance with recommended treatment and seemed motivated for surgery. One week after liver transplant he developed hypovolemic shock. lost his graft. and was retransplanted in an emergency procedure. Because of primary nonfunction of the second graft he received a third transplant. His postoperative course was complicated by numerous septic and rejection episodes. opportunistic infections, and renal and respiratory failure. resulting in six continuous months of hospitalization. After discharge, he missed his third and fourth outpatient follow-up appointments and could not be found. Three weeks later he was readmitted with cardiogenic shock, liver failure, and undetectable cyclosporine levels. He developed multisystem organ failure within 24 hours and was pronounced dead 23 days after discharge from the hospital following his third liver transplant. Case 4. A 43-year-old man with alcoholic cirrhosis, hepatitis C. a history of addiction to drugs, and antisocial personality disorder had been abstinent from alcohol and drugs for 3 and 6 years. respectively. but had served 22 months in prison for drug charges. Hospitalized twice for depression and suicidal ideation. he had attempted suicide 13 years 575

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previously. Despite the initial reluctance of the transplant team to transplant this patient. he was compliant with outpatient psychiatric care and underwent successful liver transplantation 6 months after evaluation. Ten weeks postoperatively he complained of depressed mood. hypersomnia. apathy. anhedonia. and suicidal ideation. He responded to Iluoxetine but developed akathisia. which was treated by lorazepam and lowering the Iluoxetine dose. The patient continued to complain of depression as well as passive suicidal ideation but refused inpatient psychiatric treatment. The Iluoxetine was discontinued. with resultant worsening depression and a suicidal plan. Initially he was hospitalized on the transplant unit. but he attempted to cut his arm with a knife and was transferred to psychiatry. He was started on sertraline and haloperidol. but he left the hospital against the recommendations of the psychiatric team after 6 days. One month later this patient complained of continued depression. suicidal and homicidal ideation. and auditory hallucinations as well as akathisia. The day prior to admission he had placed a knife against his abdomen to lind "numb spots" in which to insert his knife and kill himself. He was hospitalized on the psychiatric unit and attempted to stab himself with a knife. After six ECT treatments. his condition improved significantly. He was discharged on imipramine and thioridazine. He was noncompliant with follow-up and was readmitted 7 weeks later with auditory hallucinations and suicidal thoughts. He stated that his suicide plan was "to stop taking all of my medication." Because he stated his intention to stop his immunosuppressive medication. he was readmitted. He refused ECT and was restarted on thioridazine. His condition improved and he was discharged to outpatient care.

Discussion The above case histories illustrate one devastating aspect of transplantation that has rarely been discussed. Fortunately. suicide after transplantation is rare. However. the potential for its occurrence underscores the need for awareness. education. and comprehensive psychiatric evaluation and treatment. The transplant team is responsible for rationing a scarce public commodity. This imposes a duty to place organs in those patients with the greatest chance for a suc576

cessful outcome and to provide psychiatric care to patients who develop psychiatric symptoms. The risk of serious psychiatric morbidity or mortality should therefore be considered equally with the risk of physiological morbidity. Psychiatric assessment in the pretransplant or patient selection phase is an integral component of the total transplant evaluation. Careful attention should be paid to any past psychiatric history. including mood disorders. substance abuse. suicidal ideation or attempts. and episodes of delirium. This may be best accomplished by separate interviews with the patient and family members and by reviewing any psychiatric records. For patients who have been treated with corticosteroids. it is helpful to ask about any history of adverse side effects. Systematic and ongoing evaluation of patients at high risk for suicide is crucial. The psychiatric review of systems at any time during the transplant process should include specific exploration of depression. guilt. hopelessness. worthlessness. suicidal ideation. and anhedonia.'~ The mistaken belief that depression is normal for transplant patients "considering all they have been through" must be dispelled. If a transplant patient appears depressed and possibly suicidal. careful attention should be paid to characteristics associated with a high risk of imminent suicide. These include severe psychic anxiety. severe anhedonia. global insomnia. difficulty in concentration. indecision. acute abuse of alcohol or other drugs. panic attacks. the absence of responsibility for children. and a current episode of cycling affective illnesses.l~ Providing accessible inpatient and outpatient psychiatric care is an essential component of comprehensive care for the transplant patient. Close monitoring and appropriate pharmacotherapy should be instituted for patients who develop delirium. organic mental disorders. depression. mania. anxiety. or insomnia. II> Antidepressant medication should be carefully selected so as not to increase the risk of suicide by producing adverse side effects or cognitive impairment. and doses should be adjusted for patients with liver failure. 17 •1K Patient education is also an essential part of PSYCHOSOMATICS

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treatment. Patients are often relieved to learn that glucocorticoids may affect their mood and lead to depression, euphoria, mania, irritability, and mood lability. Some patients may be reluctant to admit suicidal thoughts because they fear being perceived as ungrateful for their new liver. However. they may be reassured to learn that other patients have experienced feelings of loss, hopelessness. and even thoughts of whether life is worth living. Patient support groups can provide a forum for patients to discuss these experiences with one another. There is no consensus among transplant teams or consultation-liaison psychiatrists on the definition of suicidal behavior, and difficult ethical dilemmas surround this question. For instance. some physicians define as suicide a candidate's refusal of a potentially life-saving organ, an addict's return to using drugs, or nonadherence to immunosuppressants by the patient who fully understands the consequences ofrejection. Some physicians believe. on the other hand, that lethal noncompliance must be accompanied by depression in order to be considered suicide. J~ Substantial disagreement exists about whether substance-abusing transplant patients who resume their former lifestyle after transplant are showing suicidal behavior. Clearly, however, whether biochemical or genetic factors are dom-

inant over the psychiatric. cognitive, and social factors, the substance-abusing transplant patient is at risk for both physiological and psychiatric morbidity and mortality. The patient and transplant team must agree on clear guidelines for continued abstinence with aftercare monitoring. Many questions related to the psychiatric aspects of transplantation remain, including what constitutes a predictive profile for psychiatric morbidity and suicide. Other vital areas for further discussion include quality-of-life issues and their relationship to psychiatric morbidity. survival. and cost effectiveness. All the patients whose cases are discussed above had premorbid psychiatric instability or lack of support. In retrospect, they may have been at too high a risk for transplant without continual psychiatric intervention. Although a psychiatric consultant cannot be an organ gatekeeper,19 the transplant psychiatrist has a responsibility that includes interdisciplinary collaboration to improve the transplant process and to help determine which patients are at greatest risk of suicide.

The authors acknOlrledge the assistance (~f Susan L. Smith. R.N.. M.S.: Barbara J. Lewison. B.A.: J. Michael Henderson. M.B.. Ch.B.: and Miriam Beinin. M.S. w.. L.C.S. W.

References I. Levenson JL. Olhrisch ME: Psychosocial evaluation of organ transplant candidates: a comparative survey of process. criteria. and outcomes in hcart. liver. and kidney transplantation. Psychosomatics 1993: 4:314-323 2. Riether AM. Lihh JW: Heart and liver transplantation. in Medical Psychiatric Practice. edited by Stoudemire A. Fogel BS. Washington. DC. American Psychiatric Press. 1991. Vol I. 309-346 3. Riether AM. Smith SL. Lewison BJ. et al: Quality-of-life changes and psychiatric and neurocognitive outcome after heart and liver transplantation. Transplantation 1992: 54:444-450 4. Beck AT. Steer RA. Kovacs M. et al: Hopelessness and eventual suicide: a IO-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 1985: 142:559-563 5. Beck AT. Steer RA. Beck JS. et al: Hopelessness. depression. suicidal ideation. and clinical diagnosis of depres-

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sion. Suicide Life Threat Behav 1993: 23: 139-145 6. Plutchik R. van Praag HM. Conte HR: Correlates of suicide and violence risk. III: a two-stage model of countervailing forces. Psychiatr Res 1989: 28:215-225 7. Ortalli G: Suicide by interruption of immunosuppressive therapy (Ieller). J Cardiothorac Vasc Anesth 1992: 5:644 8. Jenkins PL. Roberts DJ: Suicidal behaviour after bone marrow transplantation. Bone Marrow Transplant 1991: 7: 159-161 9. Starzl TE. Schroter GPJ. Hartmann NJ. et al: Long-term (25-year) survival after renal homotransplantation-the world experience. Transplantation Proc 199(): 22:23612365 10. Black DW, Winokur G: Suicide and psychiatric diagnosis. in Suicide Over the Life Cycle, edited by Blumenthal SJ. Kupfer DJ. Washington. DC. American Psychiatric Press. 1990. pp 135-153 II. Riether AM: Psychiatric aspects of transplantation. in

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Tissue and Organ Transplantation: Implicalions for Professional Nursing Practice. edited by Smith SL. SI. Louis. MO. Mosby Year Book. 1990. pp 117-143 Mackenzie TB. Popkin MK: Medical illness and suicide. in Suicide Over the Life Cycle. ediled by Blumenthal SJ. Kupfer DJ. Washington. DC. American Psychialric Press. 1990. pp 205-232 Vaillant GE. Blumenthal SJ: Introduction: suicide over the life cycle-risk faclors and life-span developmenl. in Suicide Over the Life Cycle. ediled by Blumenthal SJ. Kupfer DJ. Washinglon. DC. American Psychiatric Press. 1990. pp 1-14 Levenson JL. Olbrisch ME: Psychialric aspects of hean lransplantation. Psychosomatics 1993: 34: 114--123 Fawcett J. Clark DC. Busch KA: Assessing and treating the palienl al risk for suicide. Psychiatric Annals 1993:

23:244--255 16. Orbach J. Bar-Joseph H: The impact of a suicide prevention program for adolescents on suicidallendencies. hopelessness. ego identily. and coping. Suicide Life Threat Behav 1993: 23: 120-129 17. Trzepacz PT. DiManini A. Tringali R: Psychopharmacologic issues in organ lransplantation. I: pharmacokinelics in organ failure and psychiatric aspects of immunosuppressants and anli-infeclious agents. Psychosomatics 1993; 34: 199-207 18. Trzepacz PT. Levenson JL. Tringali RA: Psychopharmacology and neuropsychialric syndromes in organ transplantation. Gen Hosp Psychialry 1991: 13:233-245 19. Fox RC. Swazey JP: The Courage to Fail: A Social View of Organ Transplanl and Dialysis. Chicago.IL. UniversilY of Chicago Press. 1979

Factitious Hermaphrodism M.D. AMANDA J. SUTHERLAND, M.D. RADKA LENZ, M.D. ANDREW WARREN,

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lthough the literature is replete with case reports of patients with factitious disorder. there have been no reported cases of factitious hermaphrodism. The diagnosis of factitious disorder is often difficult because it involves distinguishing between conscious and unconscious acts and motivations. I This report highlights the necessity of obtaining a complete history. performing a thorough physical exam. obtaining collateral information. and performing indicated consultations and investigations prior to proceeding with major interventions.

Received June 23. 1993: revised November 29. 1993: accepted December 15. 1993. From Janeway Child Health Centre. Newfoundland. Canada: and Depanmenl of Psychiatry. Ottawa General Hospital. University of Ottawa. Ontario. Canada. Address correspondence to Dr. Sutherland. Depanment of Psychiatry. 4th Floor. Ottawa General Hospital. SOl Smyth Road. Ottawa. Ontario K IH 8L6. Copyright © 1994 The Academy of Psychosomatic Medicine.

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B. was a 36-year-old genetic male who claimed to be a hermaphrodite and who had been living as a female. He came to the attention of the psychiatric consultation-liaison service because of dysphoria and agitation following an orchiectomy. He was presented as a true hermaphrodite and someone for whom there had "always been some discrepancy about the exact gender." B. was on estrogens when he was referred to urology for an orchiectomy to aid in feminization. At the initial meeting with the urologist. B. stated that he had a complete set of both sex organs. with a small, retroverted uterus and an internally fused vagina and rectum. He stated that he urinated through his rectum and that he menstruated regularly. His hospital chart documented that B. had repeatedly made these statements. On physical examination, B. had atrophic testes with a normal scrotum and penis. He claimed to be menstruating and refused a rectal exam. No vaginal or urethral opening PSYCHOSOMATICS