The 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for the Psychosocial Evaluation of Adult Cardiothoracic Transplant Candidates and Candidates for Long-term Mechanical Circulatory Support.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

The milestones for psychosomatic medicine subspecialty training.

BACKGROUND: The Accreditation Council of Graduate Medical Education Milestones project is a key element in the Next Accreditation System for graduate medical education. On completing the general psychiatry milestones in 2013, the Accreditation Council of Graduate Medical Education began the process of creating milestones for the accredited psychiatric subspecialties. METHODS: With consultation from the Academy of Psychosomatic Medicine, the Accreditation Council of Graduate Medical Education appointed a working group to create the psychosomatic medicine milestones, using the general psychiatry milestones as a starting point. RESULTS: This article represents a record of the work of this committee. It describes the history and rationale behind the milestones, the development process used by the working group, and the implications of these milestones on psychosomatic medicine fellowship training. CONCLUSIONS: The milestones, as presented in this article, will have an important influence on psychosomatic medicine training programs. The implications of these include changes in how fellowship programs will be reviewed and accredited by the Accreditation Council of Graduate Medical Education and changes in the process of assessment and feedback for fellows.

Liver transplant for intentional acetaminophen overdose: a survey of transplant clinicians׳ experiences with recommendations.

BACKGROUND: In the case of fulminant hepatic failure from acetaminophen, the ability to fully evaluate patients is often compromised. When hepatic recovery is not possible and liver transplantation (LT) is required, these patients present significant medical and psychosocial challenges to liver transplant teams. In this context, decisions about candidacy are often under emergency circumstances. To date, little empirical data exist to illustrate the experiences and approaches of those clinicians responsible for performing the psychosocial assessments of these LT candidates. METHODS: We surveyed transplant mental health clinicians and discovered a wide range of opinions, approaches, and treatment planning when addressing acetaminophen overdose LT patients. RESULTS: Although LT candidacy is commonly supported, there were distinct differences in considering the contributions of suicide risk factors. In addition, although poor post-LT outcomes (repeat suicide attempts and graft failure due to nonadherence) were known to have occurred in acetaminophen overdose LT cases, many respondents did not provide long-term mental health treatment to these patients following LT. CONCLUSION: The results of the survey suggest that careful treatment planning in both the immediate and long term could improve the long-term care of these complex patients.

Psychiatric disorders as risk factors for adverse medical outcomes after solid organ transplantation.

PURPOSE OF REVIEW: Given that the prevalence of psychiatric disorders in transplant candidates and recipients is substantially higher than in the general population, and that linkages between psychiatric disorders and medical outcomes for nontransplant-related diseases have been established, it is important to determine whether psychiatric disorders predict posttransplant medical outcomes. RECENT FINDINGS: Most research has focused on the association between depression (both pretransplant and posttransplant) and posttransplant mortality. Some research has examined transplant-related morbidity outcomes, such as graft rejection, posttransplant malignancies, and infection. However, methodological limitations make it difficult to compare existing studies in this literature directly. Overall, the studies presented in this review indicate that psychiatric distress occurring in the early transplant aftermath bears a stronger relationship to morbidity and mortality outcomes than psychiatric distress occurring before transplant. SUMMARY: The literature on the impact of psychiatric conditions on the morbidity and mortality of solid organ transplant recipients remains inconclusive. More research is needed in order to investigate these associations among a broader range of psychiatric predictors, morbidity outcomes, and recipient populations. Until evidence suggests otherwise, we recommend frequent monitoring of psychiatric symptoms during the first year after transplantation to aid in early identification and treatment during this critical period of adjustment.

Alcohol and substance use in liver transplant patients.

In this article the epidemiology of substance use and substance disorders in the United States and their association with liver disease are reviewed. The relevance of tobacco use and issues of candidacy as it pertains to substance use are discussed. The use of alcohol while on the waitlist and short sobriety are also addressed. The merits of monitoring of patients are discussed, and the outcomes of these patients after liver transplantation are examined. The article concludes with a summary of recommendations for clinicians working with these patients and possible future directions for both clinical care and research.

Cognitive performance enhancement: misuse or self-treatment?

OBJECTIVE: This cross-sectional survey study examines the link between ADHD medication misuse and a positive screen for adult ADHD symptoms. METHOD: Surveys from 184 college student volunteers in Northern Virginia are collected and analyzed. RESULTS: A total of 71% of ADHD stimulant misusers screen positive for ADHD symptoms. Misusers are 7 times more likely to be symptomatic for ADHD than those who do not misuse. Also, 87% of misusers indicate that they do so for academic reasons, and 76% believe that the misuse of the ADHD stimulants improve their grades. CONCLUSION: ADHD stimulant misuse in college students is found to be strongly linked to having symptoms of adult ADHD. The desire for cognitive performance enhancement in college students may be a form of self-treatment for undiagnosed ADHD. College students need more accessibility to medical diagnosis and treatment of adult ADHD to reduce the incidence of misuse in the future.

An approach to the patient with organ failure: transplantation and end-of-life treatment decisions.

Organ transplantation offers an opportunity for extended survival and enhanced quality of life to patients with end-stage organ disease. Significant challenges are associated with both pre- and post-transplantation care, however, that require awareness of psychiatric issues in this patient population. Ventricular assist devices have added another dimension to patient care and to quality-of-life considerations. Unfortunately, effective incorporation of palliative care and end-of-life discussions is frequently overlooked during caretaking of these patients.

Psychiatric aspects of organ transplantation in critical care.

Intensive care unit teams are a critical part of the solid organ transplant process. The psychosocial issues involved during critical periods of transplantation are important for intensive care physicians and clinicians to understand to provide comprehensive care to transplant patients. This article provides a brief overview of transplant epidemiology, followed by a review of the psychosocial issues relevant to the phases of the transplant process. Considered are the pretransplant evaluation phase, psychiatric disorders in transplant patients, and cognitive impairments and delirium with additional issues specific to particular organs. Also covered are the side effects of immunosuppressive medications and special issues arising with living donors.

An overview of psychiatric issues in liver disease for the consultation-liaison psychiatrist.

Liver disease is a common cause of morbidity and mortality in the United States and elsewhere. Arising from infectious, hereditary, or toxin-induced sources, the detection of liver disease often requires a high index of suspicion. Clinical presentations are highly variable and are often accompanied by neuropsychiatric symptoms. This fact, along with an increased incidence of liver disease among patients with primary psychiatric disorders and the presence of varied drug use, complicates the tasks of providing care to patients with liver disease. To assist the consultation-liaison psychiatrist, the authors present the first of a two-part series focused on psychiatric issues in liver disease.

Managing the neuropsychiatric side effects of interferon-based therapy for hepatitis C.

Neuropsychiatric side effects are common with interferon-based therapy for chronic hepatitis C, and their prompt recognition and management is essential to effective patient care. Depression induced by interferon has been a significant cause of early treatment discontinuation in clinical trials. The need to monitor for and treat interferon-induced depression is well established, but whether to use antidepressants prophylactically remains controversial. Nonetheless, clinicians should maintain a low threshold for antidepressant therapy. Other significant neuropsychiatric side effects include anxiety, hypomania or mania, fatigue, and cognitive dysfunction. These can be additional sources of patient distress during interferon therapy and require appropriate intervention through patient education, psychotropic medications, support, and behavioral techniques.

Treatment of anxiety and depression in transplant patients: pharmacokinetic considerations.

Depressive and anxiety disorders appear during the transplant process due to psychological stressors, medications and physiological disturbances. Treatment is necessary to prevent impact on patient compliance, morbidity and mortality. Psychotropic medications provide an effective option, although most are only available as oral formulations. Because of this, they are more susceptible to alterations in pharmacokinetic behaviour arising from organ dysfunction in the pretransplant period. Kinetics are also an issue when considering potential drug-drug interactions before and after transplantation. Prior to transplant, organ dysfunction can change the pharmacokinetic behaviour of some psychotropic agents, requiring adjustment of dosage and schedules. Thoracic or abdominal organ failure may reduce drug absorption through disturbances in intestinal motility, perfusion and function. Cirrhotic patients experience increased drug bioavailability due to portosystemic shunting, and thus dosage is adjusted downward. In contrast, dosage needs to be raised when peripheral oedema expands the drug distribution volume for hydrophilic and protein-bound agents. Drug clearance for most psychotropic medications is dependent upon hepatic metabolism, which is often disrupted by endstage organ disease. Selection of drugs or their dosage may need to be adjusted to lower the risk of drug accumulation. Further adjustments in dosage may be called for when renal failure accompanies thoracic or abdominal organ failure, resulting in further impairment of clearance. Studies regarding the treatment of anxiety and depressive disorders in the medically ill are limited in number, but recommendations are possible by review of clinical and pharmacokinetic data. Selective serotonin reuptake inhibitors are well tolerated and efficacious for depression, panic disorder and post-traumatic stress disorder. Adjustments in dosage are required when renal or hepatic impairment is present. Among them, citalopram and escitalopram appear to have the least risk of drug-drug interactions. Paroxetine has demonstrated evidence supporting its use with generalised anxiety disorder. Venlafaxine is an alternative option, beneficial in depression, post-traumatic stress and generalised anxiety disorders. Nefazodone may also be considered, but there is some risk of hepatotoxicity and interactions with immunosuppressant drugs. Mirtazapine still needs to be studied further in anxiety disorders, but can be helpful for depression accompanied by anorexia and insomnia. Bupropion is effective in the treatment of depression, but data are sparse about its use in anxiety disorders. Psychostimulants are a unique approach if rapid onset of antidepressant action is desired. Acute or short-term anxiolysis is obtained with benzodiazepines, and selection of particular agents entails consideration of distribution rate, half-life and metabolic route.

Comprehensive review of hepatitis C for psychiatrists: risks, screening, diagnosis, treatment, and interferon-based therapy complications.

Hepatitis C is an RNA virus responsible for chronic infection in at least 4 million Americans. Patients are often unaware that they have contracted the virus until the appearance of long-term consequences of the infection, primarily cirrhosis and hepatocellular carcinoma. Many patients with hepatitis C have comorbid psychiatric and/or substance abuse disorders. Treatments for hepatitis C infection are based on interferon-alfa therapy and have shown increasing effectiveness in recent years; however, interferon-alfa therapy also poses significant risks for physical and neuropsychiatric side effects. Since psychiatrists often serve as primary caregivers for patients who are at higher risk for hepatitis C infection, knowledge about the diagnosis, prognosis, and treatment of this disease is needed. In the first half of this article, the authors review the epidemiology, transmission, pathophysiology and disease course of hepatitis C, as well as the neuropsychiatric complications of hepatitis C infection. They also discuss the incidence of comorbid psychiatric disorders in patients with hepatitis C infection and consider the impact of the infection on patients' quality of life. The authors then provide an overview of the clinical management of HCV infection, including screening procedures, decision-making about treatment, available treatments (interferon-alfa, pegylated interferon-alpha, combination therapy with interferon and ribavirin) and their side effects and potential drug-drug interactions, and prediction of treatment response. The authors then discuss management of the neuropsychiatric complications of treatment with interferon-alpha and ribavirin, including depression, mania and psychosis, and cognitive and neurological complications. The final section of the article focuses on special issues related to the treatment of hepatitis C infection in patients with substance abuse or dependence and/or other comorbid psychiatric illness.

Herbal and nonherbal supplements in medical-psychiatric patient populations.

Nutritional supplements remain a popular choice for patients seeking relief or prevention from a wide range of physical and mental disorders. Review of available literature finds support for some therapeutic uses, but flaws in study design (e.g., small sample sizes) and methodology (e.g., inadequate blinding and a lack of placebo control) limit the possibility of making strong recommendations. Quality-control issues also raise concerns about the safety of supplement use (see previous list). In addition, potential interactions with prescription drugs are another consideration (Table 1). By becoming more knowledgeable about the risks and benefits of nutritional supplements, psychiatrists can assist patients in making informed choices and avoiding unnecessary harm.