Psychological Outcomes of Living Liver Donors From a Multicenter Prospective Study: Results From the Adult-to-Adult Living Donor Liver Transplantation Cohort Study2 (A2ALL-2).

Although single-center and cross-sectional studies have suggested a modest impact of liver donation on donor psychological well-being, few studies have assessed these outcomes prospectively among a large cohort. We conducted one of the largest, prospective, multicenter studies of psychological outcomes in living liver donors within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study2 (A2ALL-2) consortium. In total, 271 (91%) of 297 eligible donors were interviewed at least once before donation and at 3, 6, 12, and 24 mo after donation using validated measures. We found that living liver donors reported low rates of major depressive (0-3%), alcohol abuse (2-5%), and anxiety syndromes (2-3%) at any given assessment in their first 2 years after donation. Between 4.7% and 9.6% of donors reported impaired mental well-being at various time points. We identified significant predictors for donors' perceptions of being better people and experiencing psychological growth following donation, including age, sex, relationship to recipient, ambivalence and motivation regarding donation, and feeling that donation would make life more worthwhile. Our results highlight the need for close psychosocial monitoring for those donors whose recipients died (n=27); some of those donors experienced guilt and concerns about responsibility. Careful screening and targeted, data-driven follow-up hold promise for optimizing psychological outcomes following this procedure for potentially vulnerable donors.

The obligation to say 'Thank you': heart transplant recipients' experience of writing to the donor family.

Transplant recipients are encouraged to write anonymous thank-you letters to the donor family. We prospectively explored heart transplant recipients' embodied responses to the 'obligation' to write a thank-you letter using audio/video-taped open-ended interviews (N = 27). Fifteen of the 19 participants, who wrote letters to the donor family, expressed or visually revealed significant distress about issues such as the obligation to write anonymously and the inadequacy of the 'thank-you'. Writing the thank-you letter is not a neutral experience for heart transplant recipients. Rethinking the obligatory practice regarding the thank-you letter and developing the necessary support for the recipient through this process is necessary.

Suicide risk in hepatitis C and during interferon-alpha therapy: a review and clinical update.

Chronic hepatitis C (CHC) affects over 170 million individuals worldwide and is a growing public health concern. Despite the availability of CHC treatment, specifically interferon-α and ribavirin, treatment of CHC is limited by concerns about psychiatric side effects including risks of suicide. Although depression has been the focus of neuropsychiatric complications from interferon-alpha (IFNα), emerging evidence has contributed to our understanding of IFNα-induced suicidal ideation and attempts. Using Pubmed, we performed a literature review of all English articles published between 1989 and April 1, 2010 on suicide in untreated and IFNα-treated patients with CHC. References in all identified review articles were scanned and included in our review. A total of 17 articles were identified. Studies have suggested that the first 12 weeks of IFNα therapy are the high-risk period. Moreover, the emergence of suicidal ideation can be linked to neuropsychiatric abnormalities, specifically serotonin depletion. Pretreatment with antidepressant treatment should be reserved for high-risk groups, as this may reduce the risk of depression and thus decrease the suicide risk indirectly. Although there is a paucity of literature on suicide and suicide risk during IFNα therapy for CHC, recent studies on IFNα-induced depression have provided some potential insights into suicide in this patient population. Further research examining the effects of pharmacological and nonpharmacological interventions on suicide risk during IFNα treatment is needed.

Anonymous living liver donation: donor profiles and outcomes.

There are no published series of the assessment process, profiles and outcomes of anonymous, directed or nondirected live liver donation. The outcomes of 29 consecutive potential anonymous liver donors at our center were assessed. We used our standard live liver assessment process, augmented with the following additional acceptance criteria: a logical rationale for donation, a history of social altruism, strong social supports and a willingness to maintain confidentiality of patient information. Seventeen potential donors were rejected and 12 donors were ultimately accepted (six male, six female). All donors were strongly motivated by a desire and sense of responsibility to help others. Four donations were directed toward recipients who undertook media appeals. The donor operations included five left lateral segmentectomies and seven right hepatectomies. The overall donor morbidity was 40% with one patient having a transient Clavien level 3 complication (a pneumothorax). All donors are currently well. None expressed regret about their decision to donate, and all volunteered the opinion that donation had improved their lives. The standard live liver donor assessment process plus our additional requirements appears to provide a robust assessment process for the selection of anonymous live liver donors. Acceptance of anonymous donors enlarges the donor liver pool.

Six-month and one-year followup of 23 weeks of aerobic exercise for individuals with fibromyalgia.

OBJECTIVE: To measure mood and physical function of individuals with fibromyalgia, 6 and 12 months following 23 weeks of supervised aerobic exercise. METHODS: This is a followup report of individuals who were previously enrolled in 23 weeks of land-based and water-based aerobic exercise classes. Outcomes included the 6-minute walk test, Beck Depression Inventory (BDI), State-Trait Anxiety Inventory, Arthritis Self-Efficacy Scale (ASES), Fibromyalgia Impact Questionnaire (FIQ), tender point count, patient global assessment score, and exercise compliance. Outcomes were measured at the start and end of the exercise classes and 6 and 12 months later. RESULTS: Analyses were conducted on 29 (intent-to-treat) or 18 (efficacy) subjects. Six-minute walk distances and BDI total scores were improved at followup (all analyses). BDI cognitive/affective scores were improved at the end of 23 weeks of exercise (both analyses) and at the 12-month followup (efficacy analysis only). BDI somatic scores were improved at 6-month (both analyses) and 12-month followup (intent-to-treat only). FIQ and ASES function were improved at all followup points. ASES pain was improved in efficacy analyses only (all followup points). Tender points were unchanged after 23 weeks of exercise and at followup. Exercise duration at followup (total minutes of aerobic plus anaerobic exercise in the preceding week) was related to gains in physical function (6- and 12-month followup) and mood (6-month followup). CONCLUSION: Exercise can improve physical function, mood, symptom severity, and aspects of self efficacy for at least 12 months. Exercising at followup was related to improvements in physical function and perhaps mood.

Measuring exercise-induced mood changes in fibromyalgia: a comparison of several measures.

OBJECTIVE: To compare scales measuring exercise-induced changes in mood. METHODS: Mood changes in a randomized, 23-week controlled trial of exercise were assessed using the Beck Depression Inventory (BDI), Center for Epidemiologic Studies Depression Scale (CES-D), State Trait Anxiety Inventory (STAI), Fibromyalgia Impact Questionnaire, and the Mental Health Inventory (MHI). Effect sizes and t-tests were computed on 23-week change scores. Scales were deemed to be confounded if items addressed sleep disturbances, fatigue, or effort (symptoms of both mood disturbances and fibromyalgia). RESULTS: Efficacy (15 exercise subjects) and intent-to-treat analyses (27 exercise subjects) generated medium effects for BDI (total, cognitive), MHI depression (efficacy only), and CES-D (intent-to-treat only) scales. BDI (total, cognitive), MHI (depression, positive affect, total [MHI-5]), and STAI scales distinguished exercise from control subjects at 23 weeks in all analyses. BDI somatic and CES-D scales were deemed to be confounded. CONCLUSION: We recommend the BDI cognitive, STAI, and MHI-5 scales to measure depression, anxiety, and general mood, respectively, in patients with fibromyalgia.

Illness intrusiveness among survivors of autologous blood and marrow transplantation.

BACKGROUND: Illness-induced disruptions to lifestyles, activities, and interests (i.e., illness intrusiveness) compromise subjective well-being. The authors measured illness intrusiveness in autologous blood and bone marrow transplantation (ABMT) survivors and compared the results with survivors of solid organ transplants. METHODS: Forty-four of 64 consecutive ABMT survivors referred to the University of Toronto ABMT long-term follow-up clinic completed the Illness Intrusiveness Ratings Scale (IIRS), the Affect Balance Scale (ABS), the Atkinson Life Happiness Rating (ATKLH), the Beck Hopelessness Scale (BHS), and the Center for Epidemiologic Studies Depression (CES-D) Scale. Mean time from ABMT to evaluation was 4.6 +/- 2.8 years. All patients were in remission or had stable disease at the time of evaluation. Autologous blood and bone marrow transplantation patients' IIRS scores were compared with scores reported by recipients of kidney (n = 357), liver (n = 150), lung (n = 77), and heart (n = 60) transplants. RESULTS: Mean IIRS score for the 44 ABMT patients was 37.2 +/- 17 (maximum possible score, 91; minimum possible score, 13). Higher IIRS scores correlated with lower scores on the ABS (r = -0.54; P < 0.0001), and ATKLH (r = -0.44; P = 0.004), and with higher scores on the BHS (r = 0.58; P < 0.0001) and CES-D (r = 0.48; P < 0.0001). The authors compared IIRS scores from the ABMT survivors with scores from recipients of solid organ transplants. Scores were corrected for age, gender, and time from transplant to evaluation. Corrected mean IIRS scores for the marrow (37.5), kidney (38.9), heart (40.0), lung (30.1), and liver (32.3) transplant recipients differed significantly (P < 0.0001 by analysis of covariance). Higher scores among marrow, kidney, and heart transplant survivors were caused by increased scores in the instrumental domain of the IIRS that measures disruptions in health, work, financial situation, and active recreation. CONCLUSIONS: Despite achieving a remission after ABMT, patients continue to experience illness intrusiveness compromising subjective well-being.

Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia.

OBJECTIVE: To evaluate the effect of exercise on mood and physical function in individuals with fibromyalgia. METHODS: Subjects were randomly assigned to an exercise (EX) or control (CTL) group. EX subjects participated in 3 30-minute exercise classes per week for 23 weeks. Subjects were tested at entry and at 6, 12, and 23 weeks. Tests included the Beck Depression Inventory (BDI), 6-minute walk, State-Trait Anxiety Inventory (STAI), Mental Health Inventory (MHI), Fibromyalgia Impact Questionnaire (FIQ), Arthritis Self-Efficacy Scale (ASES), and a measure of tender points and knee strength. RESULTS: Fifty subjects (27 EX, 23 CTL) completed the study, and 31 (15 EX, 16 CTL) met criteria for efficacy analyses. In efficacy analyses, significant improvements were seen for EX subjects in 6-minute walk distances, BDI (total, cognitive/ affective), STAI, FIQ, ASES, and MHI (3 of 5 subscales) scores. These effects were reduced but remained during intent-to-treat analyses. CONCLUSION: Exercise can improve the mood and physical function of individuals with fibromyalgia.

Stress, coping, and depression in non-ulcer dyspepsia patients.

Thirty adults with upper gastrointestinal symptoms in the absence of structural organic disease diagnosed with non-ulcer dyspepsia (NUD) were compared to 30 healthy adults who had visited the hepatobiliary clinic for medical evaluation of non-organic complaints without NUD. Medical investigation in both groups were negative. Before independent gastrointestinal physicians conducted diagnostic evaluations, all subjects were evaluated for anxiety and depressive symptoms, stressful life events, coping style, and social support. The measures included Symptom Checklist 90-Revised (SCL-90-R), Beck Depression Inventory (BDI), Spielberger State-Trait Anxiety Inventory (STAI), Ways of Coping Checklist, and Interpersonal Support Evaluation List, and a self-report questionnaire, which measured the quantity of perceived stressful life events. The NUD patients reported significantly more symptoms of depression, more perceived stressful life events, less problem-focused coping, and less social support than the control subjects. Depressive symptoms were negatively correlated with interpersonal support, whereas, problem-focused coping was positively correlated with interpersonal support in the NUD patients. The two groups did not differ significantly in terms of anxiety and emotion-focused coping. The implications of these findings for the diagnosis and treatment of NUD are discussed.

Religious altruism and organ donation.

Clinicians performing psychiatric assessments of potential organ donors must consider the motivations behind an act that is--strictly in terms of its physiological implications--entirely altruistic. The authors present two case reports in which proposed kidney donors conceptualized their offers exclusively in terms of their religious beliefs and not in terms of kinship or emotional intimacy with the intended recipients. The negative reactions of some clinicians to the offers reveal the readiness with which religious beliefs can be pathologized and the way in which biological relationships can unduly restrict the clinical understanding of healthy altruism.

Gender and psychosomatic aspects of ischemic heart disease.

While women and their doctors have traditionally worried about mortality from breast and gynecological malignancies, over the past 5 years they have come to realize that ischemic cardiac disease (IHD) is the number one killer of women in most Western countries. This has led to public and professional education campaigns and a new emphasis on gender and gender-specific research in IHD. Unfortunately, this literature remains poorly developed and much work remains to be done. Even in samples in which there may be sufficient numbers to allow for the evaluation of gender and gender differences, these important analyses have often been overlooked. This article provides a review of what is known about gender and gender differences in psychosocial and behavioral issues in IHD.

The role of loss in treatment outcomes of persistent somatization.

The present study examines the effect of loss on treatment outcome in 92 persistently somatizing patients treated in an inpatient program. Patients were divided into one of three groups depending on the form of loss they experienced: early loss (loss of a parent before the age of 17, N = 25); recent loss (bereavement within the last 2 years, N = 21); or no loss (N = 46). The results indicate that patients experiencing an early loss had the poorest treatment outcome. The early loss group was characterized by poorer social adjustment prior to entry into the program compared with the recent loss group and a greater incidence of dependent personality disorder. The recent loss group showed the best outcome following treatment. The results support the concept that persistent somatization may arise from many precipitating factors. Assessing loss experiences in the patient may be an important factor in developing appropriate treatment strategies.

Depression in anorexia nervosa and bulimia nervosa: discriminating depressive symptoms and episodes.

In a clinical sample of 198 female patients with anorexia nervosa (N = 83) and bulimia nervosa (N = 115), 43% met criteria for major depression using the Structured Clinical Interview for DSMIII-R. This group had a mean score of 30.9 +/- 8.7 on the Beck Depression Inventory (BDI) which was significantly higher than the BDI mean score of 20.5 +/- 8.9 among the remainder of the sample (p < 0.0001). A score of 26 yielded the highest levels of sensitivity and specificity, while five items from the BDI (loss of satisfaction, discouragement, weight loss, suicidal ideation and decision-making) correctly classified approximately 80% of subjects into "depression-positive" or "depression-negative" categories. Detection of co-morbid depression in patients with eating disorders may have practical implications for treatment.

Psychiatric consultation in the eastern Canadian Arctic: II. Referral patterns, diagnoses and treatment.

The clinical activities of the Baffin Consultation Service of the Clarke Institute of Psychiatry were examined. Demographic and clinical data are described based on clinical interviews and questionnaire items from 581 initial psychiatric referrals. More women than men were referred to the service; the mean age of the patients seen was 27.3 +/- 13.4 years. The majority of referred patients were single and unemployed. The most common reasons for referral were depression, suicidal ideation, suicide attempts and family problems. The major diagnoses made were adjustment reactions and depressive disorders. Treatment was largely carried out in an outpatient setting through local health care professionals. The implications of these findings for this population and the development of community-based intervention programs are discussed.

Psychiatric consultation in the eastern Canadian Arctic: I. Development and evolution of the Baffin Psychiatric Consultation Service.

The Baffin Consultation Service of the Clarke Institute of Psychiatry has been providing psychiatric consultation services to the Baffin Island region of the Eastern Canadian Arctic since 1971. This report describes the background history, development and evolution of the service. Attention is focused on aspects of the consultation visits, educational activities of the project and the development of a mental health network. It is suggested that this is a useful model for the provision of psychiatric services to remote areas with limited resources.

Psychiatric consultation in the eastern Canadian Arctic: III. Mental health issues in Inuit women in the eastern Arctic.

This report describes mental health issues affecting Inuit women as seen in psychiatric consultation. Recent public and governmental attention has focused on the emotional and behavioural sequelae of rapid cultural change, spousal assault and sexual violence. The process of psychiatric consultant with the Inuit woman patient will be described. The need for innovative, community-based treatment strategies in this population will be emphasized.

Somatization, illness attribution and the sociocultural psychiatry of chronic fatigue syndrome.

In addition to epidemiological and neurobiological perspectives on the relationship between chronic fatigue syndrome (CFS) and psychiatric disorders there has been increasing interest in the role of cognitive-behavioural, psychological, psychodynamic and social factors in the psychiatric aspects of this syndrome. These factors may be important in the initiation and/or maintenance of CFS and play important roles in the misdiagnosis of primary psychopathology as CFS. They may be important targets for intervention and treatment. This paper examines the relevance of the following issues for better understanding the relationship between CFS and the results of psychiatric studies: (1) the concepts of somatization and abnormal illness behaviour; (2) the role of patients' illness attributions; (3) psychological and psychodynamic constructs such as depressive vulnerability occurring in individuals dependent upon achievement for the maintenance of self-esteem and euthymic mood, perfectionism, and helplessness; (4) the role of personality characteristics and styles; (5) the potential iatrogenic role of the health care system in producing disability in individuals with a diagnosis of CFS; (6) the role of the media and other sociocultural forces in the patient's choice of the CFS label; and (7) the impact of the CFS label on the patient. The importance of differentiating between initiating and maintaining or perpetuating factors is emphasized.

Assessment of regional cerebral perfusion by 99Tcm-HMPAO SPECT in chronic fatigue syndrome.

Chronic fatigue syndrome (CFS) is a severely disabling illness of uncertain aetiology. It is characterized by a chronic, sustained or fluctuating sense of debilitating fatigue without any other known underlying medical conditions. It is also associated with both somatic and neuropsychological symptoms. Both physical and laboratory findings are usually unremarkable. Regional cerebral blood flow (rCBF) was assessed in 60 clinically defined CFS patients and 14 normal control (NC) subjects using 99Tcm-hexamethylpropyleneamine oxime (99Tcm-HMPAO) single photon emission computed tomography (SPECT). Compared with the NC group, the CFS group showed significantly lower cortical/cerebellar rCBF ratios, throughout multiple brain regions (P < 0.05). Forty-eight CFS subjects (80%) showed at least one or more rCBF ratios significantly less than normal values. The major cerebral regions involved were frontal (38 cases, 63%), temporal (21 cases, 35%), parietal (32 cases, 53%) and occipital lobes (23 cases, 38%). The rCBF ratios of basal ganglia (24 cases, 40%) were also reduced. 99Tcm-HMPAO brain SPECT provided objective evidence for functional impairment of the brain in the majority of the CFS subjects. The findings may not be diagnostic of CFS but 99Tcm-HMPAO SPECT may play an important role in clarifying the pathoaetiology of CFS. Further studies are warranted.

Inpatient treatment of persistent somatization.

Patients with disabling, persistent somatization pose significant challenges in clinical management. This study describes 92 patients treated on an inpatient psychosomatic medicine unit for persistent somatization. The most important factor in defining clinically significant subgroups of these patients was mood. Compared with depressed somatizing patients, nondepressed somatizing patients had chronic illnesses of early onset, had symptoms that were not correlated with current life stressors, and were generally unresponsive to treatment. There were few clinical predictors of treatment outcome apart from the duration of symptoms, the presence of mood disturbance, and a history of stable interpersonal relationships.

Neurasthenia and chronic fatigue syndrome: the role of culture in the making of a diagnosis.

Chronic fatigue syndrome is an increasingly popular diagnosis consisting of multiple psychiatric and somatic symptoms. It bears a striking resemblance to the nineteenth-century diagnosis of neurasthenia. Both disorders arose during periods characterized by a preoccupation with commerce and material success and major changes in the role of women. They illustrate the role of culture in the development of a new diagnosis that emphasizes a "medical" rather than "psychiatric" etiology. The authors argue that chronic fatigue syndrome will meet the same fate as neurasthenia--a decline in social value as it is demonstrated that the majority of its sufferers are experiencing primary psychiatric disorders or psychophysiological reactions and that the disorder is often a culturally sanctioned form of illness behavior.